Provider Demographics
NPI:1740289990
Name:STACY, DAVID RAY (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:RAY
Last Name:STACY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2974 N ALMA SCHOOL ROAD
Mailing Address - Street 2:#3
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-6713
Mailing Address - Country:US
Mailing Address - Phone:480-899-0188
Mailing Address - Fax:480-899-0199
Practice Address - Street 1:2974 N ALMA SCHOOL ROAD
Practice Address - Street 2:#3
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-6713
Practice Address - Country:US
Practice Address - Phone:480-899-0188
Practice Address - Fax:480-899-0199
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ224152W00000X, 152WL0500X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ035354Medicaid
AZZ0000PFDVJMedicare ID - Type UnspecifiedINDIVIDUAL NUMBER
AZT76754Medicare UPIN
T76754Medicare UPIN
ZWDBNWMedicare PIN
AZ5701050001Medicare NSC