Provider Demographics
NPI:1508154881
Name:BAUGAARD, STACEY LANA (OD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:LANA
Last Name:BAUGAARD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 HAMILTON ST PH 107
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-4201
Mailing Address - Country:US
Mailing Address - Phone:267-615-1502
Mailing Address - Fax:
Practice Address - Street 1:100 W BIG BEAVER RD
Practice Address - Street 2:SUITE 655
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-5206
Practice Address - Country:US
Practice Address - Phone:419-874-0393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-20
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002515152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist