Provider Demographics
NPI:1457551657
Name:DAVIS, STACY ANN MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:ANN MARIE
Last Name:DAVIS
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 1:95 BULLDOG BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3332
Mailing Address - Country:US
Mailing Address - Phone:321-727-2990
Mailing Address - Fax:321-724-0455
Practice Address - Street 1:1334 VALENTINE ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3128
Practice Address - Country:US
Practice Address - Phone:321-676-1870
Practice Address - Fax:321-768-2172
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME105521207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1082606OtherCAREPLUS
FL149KAOtherBCBS
FL59-3169815OtherBEECHSTREET
FL59-3169815OtherCOVENTRY/CCN/FIRST HEALTH
FL59-3169815OtherNPPN/COALITION AMERICA
FL59-3169815OtherTRICARE
FLPRO11849OtherQUALITY HEALTH PLAN
FL3666528OtherCIGNA
FL3666528OtherGREATWEST
FL59-3169815OtherIHG/HEALTHSMART
FL6573631OtherAETNA HMO
FL581795OtherWELLCARE
FL59-3169815OtherMULTIPLAN
FL59-3169815OtherEVOLUTIONS
FL59-3169815OtherUNITED HEALTHCARE
FL9787626OtherAETNA PPO
FL0000000OtherFLORIDA DOCTORS INS/MALPRACTICE CARRIER
FL59-3169815OtherHUMANA CHOICE
FL003136400Medicaid
FLDP836ZMedicare PIN