Provider Demographics
NPI:1588616569
Name:GOUZENNE, STACEY RENEE (MD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:RENEE
Last Name:GOUZENNE
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 1:721 CORINTHIAN PL
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-2471
Mailing Address - Country:US
Mailing Address - Phone:704-806-9865
Mailing Address - Fax:
Practice Address - Street 1:4221 TUCKASEEGEE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-2801
Practice Address - Country:US
Practice Address - Phone:704-806-9865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9500917207P00000X
SC23329207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC36407OtherBLUE CROSS
NC8936407Medicaid
NCP00131634Medicare PIN
NC36407OtherBLUE CROSS
NC8936407Medicaid