Provider Demographics
NPI:1427014075
Name:WENGER, STACEY ALLAN (OD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:ALLAN
Last Name:WENGER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14901 N DALE MABRY HWY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-1801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14901 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-1801
Practice Address - Country:US
Practice Address - Phone:813-960-8958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-24
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 2760152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620772300Medicaid
FL620772300Medicaid
FL20575 CMedicare ID - Type Unspecified