Provider Demographics
NPI:1275639254
Name:HARBIN, STACY L (MD)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:HARBIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3871 E HIGHWAY 98 STE 200
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-5302
Practice Address - Country:US
Practice Address - Phone:850-229-5833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31761208600000X
FLME108578208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000329454OtherBCBS PROVIDER NUMBER
KY31761OtherLICENSE
KY64317613Medicaid
ME108578OtherFLORDIA MEDICAL LICENSE
0903611Medicare PIN
D29681Medicare UPIN
KYP00126352Medicare PIN
ME108578OtherFLORDIA MEDICAL LICENSE
0735782Medicare PIN
KY00151011Medicare PIN