Provider Demographics
NPI:1982864179
Name:COULTHARD, STACY LAUREN (MD)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:LAUREN
Last Name:COULTHARD
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 1:620 JOHN PAUL JONES CIR
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23708-2111
Mailing Address - Country:US
Mailing Address - Phone:757-953-4455
Mailing Address - Fax:
Practice Address - Street 1:620 JOHN PAUL JONES CIR
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708-2111
Practice Address - Country:US
Practice Address - Phone:757-953-4455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2023-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101246005207R00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine