Provider Demographics
NPI:1578741138
Name:STANLEY, ATOSSA AUDREY (MD)
Entity Type:Individual
Prefix:DR
First Name:ATOSSA
Middle Name:AUDREY
Last Name:STANLEY
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 1:2647 GATEWAY RD STE 105-385
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92009-1755
Mailing Address - Country:US
Mailing Address - Phone:760-931-7864
Mailing Address - Fax:
Practice Address - Street 1:2647 GATEWAY RD STE 105-385
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92009-1755
Practice Address - Country:US
Practice Address - Phone:760-931-7864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-06
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA89617207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1578851Medicaid
CAH71284Medicare UPIN