Provider Demographics
NPI:1629004650
Name:BROWN, STACEY LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:LEE
Last Name:BROWN
Suffix:
Gender:M
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:PO BOX 275
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93515-0275
Mailing Address - Country:US
Mailing Address - Phone:760-873-8982
Mailing Address - Fax:760-873-3198
Practice Address - Street 1:150 PIONEER LN
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-2556
Practice Address - Country:US
Practice Address - Phone:760-873-8982
Practice Address - Fax:760-873-3198
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54711207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ270912Medicare ID - Type Unspecified
G91714Medicare UPIN