Provider Demographics
NPI:1598732471
Name:POOLE, STACIA (MD)
Entity Type:Individual
Prefix:
First Name:STACIA
Middle Name:
Last Name:POOLE
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 1:930 S HARBOR CITY BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-1901
Mailing Address - Country:US
Mailing Address - Phone:321-752-1599
Mailing Address - Fax:321-956-9907
Practice Address - Street 1:930S HARBOR CITY BLVD 101
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1901
Practice Address - Country:US
Practice Address - Phone:321-752-1599
Practice Address - Fax:321-956-9907
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME51873207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
070007530OtherRAIL ROAD MEDICARE
FL373042500Medicaid
070007530OtherRAIL ROAD MEDICARE
F63782Medicare UPIN