Provider Demographics
NPI:1164498572
Name:BEAN, STACY E (OD)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:E
Last Name:BEAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 PRINCETON ST
Mailing Address - Street 2:
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-1408
Mailing Address - Country:US
Mailing Address - Phone:978-977-0190
Mailing Address - Fax:
Practice Address - Street 1:40 ENON ST
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-1168
Practice Address - Country:US
Practice Address - Phone:978-922-7120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-24
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3778152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0392057Medicaid
MAU46082Medicare UPIN
MAW15947Medicare ID - Type Unspecified