Provider Demographics
NPI:1891968293
Name:RICHARDSON, STACY EMMANUEL (DO, EDD)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:EMMANUEL
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:DO, EDD
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 1960
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72403-1960
Mailing Address - Country:US
Mailing Address - Phone:870-936-8000
Mailing Address - Fax:870-936-2228
Practice Address - Street 1:4802 E JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-8413
Practice Address - Country:US
Practice Address - Phone:870-936-8000
Practice Address - Fax:870-936-2228
Is Sole Proprietor?:No
Enumeration Date:2008-04-07
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-6218207P00000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR179973003Medicaid