Provider Demographics
NPI:1265567804
Name:CRAWFORD, STACEY MICHELLE WALLACE (MD)
Entity type:Individual
Prefix:DR
First Name:STACEY
Middle Name:MICHELLE WALLACE
Last Name:CRAWFORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:MICHELLE
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2700 STANLEY GAULT PKWY STE 129
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5176
Mailing Address - Country:US
Mailing Address - Phone:502-489-6613
Mailing Address - Fax:
Practice Address - Street 1:4004 DUPONT CIR STE 230
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207
Practice Address - Country:US
Practice Address - Phone:502-893-1333
Practice Address - Fax:502-899-9576
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY440882085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology