Provider Demographics
NPI:1659647386
Name:PORTER, STACY (MD)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:PORTER
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 1:1300 CRANE ST
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-4260
Mailing Address - Country:US
Mailing Address - Phone:650-498-7080
Mailing Address - Fax:650-324-6279
Practice Address - Street 1:1300 CRANE ST
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-4260
Practice Address - Country:US
Practice Address - Phone:650-498-7080
Practice Address - Fax:650-324-6279
Is Sole Proprietor?:No
Enumeration Date:2012-03-27
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA126790207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine