Provider Demographics
NPI:1528044823
Name:EMBRY, STACEY O (OD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:O
Last Name:EMBRY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-1628
Mailing Address - Country:US
Mailing Address - Phone:812-477-8696
Mailing Address - Fax:812-477-1874
Practice Address - Street 1:2700 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-1628
Practice Address - Country:US
Practice Address - Phone:812-477-8696
Practice Address - Fax:812-477-1874
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002531152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN18002531OtherSTATE LICENSE NUMBER
IN100320130AMedicaid
INU20700Medicare UPIN
IN100320130AMedicaid
IN18002531OtherSTATE LICENSE NUMBER