Provider Demographics
NPI:1790948073
Name:GRUBER, STACEY (MD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:
Last Name:GRUBER
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 1:943 S BENEVA RD STE 306
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34232-2499
Mailing Address - Country:US
Mailing Address - Phone:941-955-1108
Mailing Address - Fax:941-954-4440
Practice Address - Street 1:11715 RANGELAND PKWY
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34211-9529
Practice Address - Country:US
Practice Address - Phone:941-538-0087
Practice Address - Fax:941-538-0078
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1518512084N0400X, 2084N0400X
WI59961-202084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000000215Medicare Oscar/Certification
WIK400124959Medicare Oscar/Certification
WIK400124557Medicare Oscar/Certification