Provider Demographics
NPI:1992391809
Name:BETZER, STACY A
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:A
Last Name:BETZER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17095 COUNTY RD 87
Mailing Address - Street 2:
Mailing Address - City:CECIL
Mailing Address - State:OH
Mailing Address - Zip Code:45821-9632
Mailing Address - Country:US
Mailing Address - Phone:419-670-4675
Mailing Address - Fax:
Practice Address - Street 1:17095 COUNTY RD 87
Practice Address - Street 2:
Practice Address - City:CECIL
Practice Address - State:OH
Practice Address - Zip Code:45821-9632
Practice Address - Country:US
Practice Address - Phone:419-670-4675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-15
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.079429207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine