Provider Demographics
NPI:1508868498
Name:ACKERMAN, STACEY L (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:ACKERMAN
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 1:1930 S BROAD ST UNIT 9
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-2328
Mailing Address - Country:US
Mailing Address - Phone:215-339-8100
Mailing Address - Fax:215-339-8103
Practice Address - Street 1:1930 S BROAD ST UNIT 9
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-2328
Practice Address - Country:US
Practice Address - Phone:215-339-8100
Practice Address - Fax:215-339-8103
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD031968E207W00000X
NJ25MA04606000207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0903906Medicaid
437423CEWMedicare ID - Type Unspecified
PA0903906Medicaid