Provider Demographics
NPI:1417945270
Name:MARTIN, STACEY W (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:W
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:STACEY
Other - Middle Name:W
Other - Last Name:WYNDHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 71061
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28272-1061
Mailing Address - Country:US
Mailing Address - Phone:704-455-6521
Mailing Address - Fax:704-455-3078
Practice Address - Street 1:4315 PHYSICIANS BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:HARRISBURG
Practice Address - State:NC
Practice Address - Zip Code:28075-7431
Practice Address - Country:US
Practice Address - Phone:704-455-6521
Practice Address - Fax:704-455-3078
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9901251207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891289AMedicaid
NC2286671BMedicare PIN