Provider Demographics
NPI:1235263385
Name:PHAN, STACEY THAO (DO)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:THAO
Last Name:PHAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 GREEN MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-3957
Mailing Address - Country:US
Mailing Address - Phone:405-245-0747
Mailing Address - Fax:
Practice Address - Street 1:1300 FRANKLIN AVE STE 100
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-3676
Practice Address - Country:US
Practice Address - Phone:309-268-3455
Practice Address - Fax:309-268-5620
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice