Provider Demographics
NPI:1497886048
Name:WHITELOCK, STACY ELEANOR (MD)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:ELEANOR
Last Name:WHITELOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:ELEANOR
Other - Last Name:THURBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2141 N HARBOR BLVD STE 25000
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-3830
Mailing Address - Country:US
Mailing Address - Phone:714-626-8650
Mailing Address - Fax:714-626-8696
Practice Address - Street 1:2141 N HARBOR BLVD
Practice Address - Street 2:SUITE 25000
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3827
Practice Address - Country:US
Practice Address - Phone:714-626-8650
Practice Address - Fax:714-626-8696
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA84206207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA84206AMedicare PIN