Provider Demographics
NPI:1760407787
Name:BERRONG, STACY J (DO)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:J
Last Name:BERRONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3400 DATA DR 1ST
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:916-379-2861
Mailing Address - Fax:916-858-3205
Practice Address - Street 1:632 W GIBSON RD
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695
Practice Address - Country:US
Practice Address - Phone:530-666-1631
Practice Address - Fax:530-668-2697
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8432207Q00000X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00745159OtherMEDICARE RAILROAD
CA00AX84320Medicaid
CA020A84320OtherBLUE SHIELD
CA00AX84320Medicaid
CADG148ZMedicare PIN
CA020A84320OtherBLUE SHIELD