Provider Demographics
NPI:1467406991
Name:STACY, TADGY D (MD)
Entity Type:Individual
Prefix:DR
First Name:TADGY
Middle Name:D
Last Name:STACY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 WALL ST
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-6302
Mailing Address - Country:US
Mailing Address - Phone:405-321-5114
Mailing Address - Fax:405-321-6482
Practice Address - Street 1:808 WALL ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-6302
Practice Address - Country:US
Practice Address - Phone:405-321-5114
Practice Address - Fax:405-321-6482
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19838208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKU15403Medicare UPIN