Provider Demographics
NPI:1750361523
Name:BERCKES, STACY JOHN (MD)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:JOHN
Last Name:BERCKES
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 1:111 WATERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-9541
Mailing Address - Country:US
Mailing Address - Phone:352-735-3313
Mailing Address - Fax:352-735-3711
Practice Address - Street 1:111 WATERMAN AVE
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-9541
Practice Address - Country:US
Practice Address - Phone:352-735-3313
Practice Address - Fax:352-735-3711
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0043723207L00000X, 207LP2900X, 208VP0000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL069131300Medicaid
FL050031800OtherRAILROAD MEDICARE
FL62496Medicare ID - Type Unspecified
FL069131300Medicaid