Provider Demographics
NPI:1215217096
Name:PILKINGTON, STACEY (DO)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:PILKINGTON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:SEASTROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5365 SPINE RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-3324
Mailing Address - Country:US
Mailing Address - Phone:303-530-9325
Mailing Address - Fax:
Practice Address - Street 1:5365 SPINE RD STE C
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-3324
Practice Address - Country:US
Practice Address - Phone:303-530-9325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-24
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLUO2794208D00000X
CODR.0054787207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO31507832Medicaid
CO31507832Medicaid