Provider Demographics
NPI:1467089888
Name:STACY, PETER JOHN (DO)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JOHN
Last Name:STACY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2555 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-6255
Mailing Address - Country:US
Mailing Address - Phone:937-775-8148
Mailing Address - Fax:
Practice Address - Street 1:2555 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-6255
Practice Address - Country:US
Practice Address - Phone:937-775-8148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH58.0316882084P0800X
390200000X
MO2022038659390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry