Provider Demographics
NPI:1457348344
Name:O'SULLIVAN, STACY (MD)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:
Last Name:O'SULLIVAN
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 1:8086 S YALE AVE # 258
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-9003
Mailing Address - Country:US
Mailing Address - Phone:918-523-5437
Mailing Address - Fax:918-523-5438
Practice Address - Street 1:7412 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-7029
Practice Address - Country:US
Practice Address - Phone:918-523-5437
Practice Address - Fax:918-523-5438
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21759208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100091570AMedicaid