Provider Demographics
NPI:1679592349
Name:WASHINGTON, STACY MARIA (OD)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:MARIA
Last Name:WASHINGTON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5764 SHADOW BEND DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89135-1252
Mailing Address - Country:US
Mailing Address - Phone:714-600-9982
Mailing Address - Fax:
Practice Address - Street 1:2120 E CALVADA BLVD
Practice Address - Street 2:
Practice Address - City:PAHRUMP
Practice Address - State:NV
Practice Address - Zip Code:89048-5805
Practice Address - Country:US
Practice Address - Phone:775-727-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13105152W00000X
NV732152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM17773580Medicaid