Provider Demographics
NPI:1265632897
Name:LACY-STALLWORTH, CYNTHIA (OD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:LACY-STALLWORTH
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 1:6331 STENTON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19138-1129
Mailing Address - Country:US
Mailing Address - Phone:215-548-5949
Mailing Address - Fax:215-548-0836
Practice Address - Street 1:6331 STENTON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19138-1129
Practice Address - Country:US
Practice Address - Phone:215-548-5949
Practice Address - Fax:215-548-0386
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX06786T152W00000X
PAOET009016152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01560081Medicaid
PA00842171Medicare UPIN