Provider Demographics
NPI:1700978319
Name:DICKENSON, STACEY D (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:D
Last Name:DICKENSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:252 RURAL ACRES DR
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-3503
Mailing Address - Country:US
Mailing Address - Phone:304-252-8551
Mailing Address - Fax:304-252-1790
Practice Address - Street 1:252 RURAL ACRES DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3503
Practice Address - Country:US
Practice Address - Phone:304-252-8551
Practice Address - Fax:304-252-1790
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20007208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
G21540OtherHEALTH NET
WV54504Medicaid
WV6700460000Medicaid
2136163OtherUNITEDHEALTLHCARE
323741OtherCARELINK
WV58599Medicaid
WV54504Medicaid