Provider Demographics
NPI:1225232309
Name:LEE, STACY L (MD)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 92038
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-0101
Mailing Address - Country:US
Mailing Address - Phone:817-749-2001
Mailing Address - Fax:940-483-1568
Practice Address - Street 1:300 MIRON DR
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-7862
Practice Address - Country:US
Practice Address - Phone:817-749-2000
Practice Address - Fax:817-749-2020
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN26232085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
BP1-0026377OtherINSTITUTIONAL PERMIT