Provider Demographics
NPI:1659389039
Name:STACY, DONNIE R (MD)
Entity Type:Individual
Prefix:
First Name:DONNIE
Middle Name:R
Last Name:STACY
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 1:101 HOSPITAL BLVD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-3769
Mailing Address - Country:US
Mailing Address - Phone:812-282-3899
Mailing Address - Fax:812-282-4172
Practice Address - Street 1:3920 S DUPONT SQ
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4615
Practice Address - Country:US
Practice Address - Phone:502-721-0116
Practice Address - Fax:812-285-6010
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1109712085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK008661Medicaid
KYK25891Medicare PIN
KYI25033Medicare UPIN