Provider Demographics
NPI:1700814639
Name:MCCLURE, STACEY DALE (MD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:DALE
Last Name:MCCLURE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2730 W AGUA FRIA FWY STE 103
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-7202
Mailing Address - Country:US
Mailing Address - Phone:480-699-2472
Mailing Address - Fax:480-699-4372
Practice Address - Street 1:2730 W AGUA FRIA FWY STE 103
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-7202
Practice Address - Country:US
Practice Address - Phone:480-699-2472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34081207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ945892Medicaid
AZ945892Medicaid
AZI34949Medicare UPIN