Provider Demographics
NPI:1497702880
Name:CONVILLE, STACY D (MD)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:D
Last Name:CONVILLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E VAUGHN AVE
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-5950
Mailing Address - Country:US
Mailing Address - Phone:318-251-8232
Mailing Address - Fax:318-251-8255
Practice Address - Street 1:1809 NORTHPOINT LANE
Practice Address - Street 2:SUITE 102
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270
Practice Address - Country:US
Practice Address - Phone:318-251-8232
Practice Address - Fax:318-251-8255
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA026106207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1052931Medicaid
LA1052931Medicaid
LA4J941CX79Medicare PIN
LAL43793Medicare UPIN