Provider Demographics
NPI:1457453375
Name:STACY, CHARLES B JR (MD)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:B
Last Name:STACY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5 E 98TH ST
Mailing Address - Street 2:7TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6501
Mailing Address - Country:US
Mailing Address - Phone:212-241-0022
Mailing Address - Fax:212-241-4350
Practice Address - Street 1:5 E 98TH ST
Practice Address - Street 2:7TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6501
Practice Address - Country:US
Practice Address - Phone:212-241-0022
Practice Address - Fax:212-241-4350
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1373772084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NS1858OtherOXFORD
B79925Medicare UPIN
94A591Medicare ID - Type Unspecified