Provider Demographics
NPI:1346267077
Name:MCBROOM, STACY (DO)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:MCBROOM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 122525
Mailing Address - Street 2:DEPT 2525
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75312-2525
Mailing Address - Country:US
Mailing Address - Phone:337-494-2772
Mailing Address - Fax:337-494-2928
Practice Address - Street 1:2016 OAK PARK BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-7828
Practice Address - Country:US
Practice Address - Phone:337-477-8861
Practice Address - Fax:337-477-3092
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LADO000034208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1318540Medicaid
LA4J998CW92Medicare PIN
F77469Medicare UPIN
LA1318540Medicaid