Provider Demographics
NPI:1467089888
Name:STACY, PETER JOHN (DO)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:JOHN
Last Name:STACY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5427 EAST MADERA ST
Mailing Address - Street 2:BUILDING 4339
Mailing Address - City:DAVIS MONTHAN AFB
Mailing Address - State:AZ
Mailing Address - Zip Code:85707
Mailing Address - Country:US
Mailing Address - Phone:520-228-4357
Mailing Address - Fax:
Practice Address - Street 1:18230 SILVER CREEK STREET
Practice Address - Street 2:BUILDING 392, MDG, SOUTH
Practice Address - City:BUCKLEY SFB
Practice Address - State:CO
Practice Address - Zip Code:80011
Practice Address - Country:US
Practice Address - Phone:720-847-6451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20220386592084P0800X, 2084P0800X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry