Provider Demographics
NPI:1790779676
Name:RAINES, STACEY DELANE (OD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:DELANE
Last Name:RAINES
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:PO BOX 17287
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72403-6723
Mailing Address - Country:US
Mailing Address - Phone:870-336-3937
Mailing Address - Fax:870-336-3934
Practice Address - Street 1:2704 ALEXANDER DR
Practice Address - Street 2:SUITE E
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-7070
Practice Address - Country:US
Practice Address - Phone:870-336-3937
Practice Address - Fax:870-336-3934
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2454152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR130329722Medicaid
AR49100OtherBLUE CROSS BLUE SHIELD
AR5069225OtherAETNA
AR696627OtherOPTICHOICE
AR25158OtherSPECTERA
AR5069225OtherAETNA
AR130329722Medicaid