Provider Demographics
NPI:1891779369
Name:WALLACH, STACEY J (MD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:J
Last Name:WALLACH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4860 Y ST
Mailing Address - Street 2:OB/GYN, SUITE 2500, ACC
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2307
Mailing Address - Country:US
Mailing Address - Phone:916-734-6930
Mailing Address - Fax:916-734-6666
Practice Address - Street 1:4860 Y ST
Practice Address - Street 2:OB/GYN, SUITE 2500, ACC
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2307
Practice Address - Country:US
Practice Address - Phone:916-734-6930
Practice Address - Fax:916-734-6666
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG68624207V00000X
CAA68624207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive Surgery
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A686240Medicaid
CA00A686240Medicaid
CAG96323Medicare UPIN