Provider Demographics
NPI:1407918378
Name:STACY, L DAVID JR (MD)
Entity Type:Individual
Prefix:DR
First Name:L
Middle Name:DAVID
Last Name:STACY
Suffix:JR
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 1:28 BRIGHTON RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1549
Mailing Address - Country:US
Mailing Address - Phone:404-351-5620
Mailing Address - Fax:404-355-5620
Practice Address - Street 1:28 BRIGHTON RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1549
Practice Address - Country:US
Practice Address - Phone:404-351-5620
Practice Address - Fax:404-355-5620
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA10670174400000X
GA10670207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA22CDBHSMedicare ID - Type UnspecifiedMEDICARE
GAE19972Medicare UPIN