Provider Demographics
NPI:1780607606
Name:BRAFF, STACY L (MD)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:BRAFF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:LYNN
Other - Last Name:PEARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1605 CHESTER BLVD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1610
Mailing Address - Country:US
Mailing Address - Phone:765-373-8253
Mailing Address - Fax:765-488-0656
Practice Address - Street 1:1605 CHESTER BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1610
Practice Address - Country:US
Practice Address - Phone:765-373-8253
Practice Address - Fax:765-488-0656
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01066923A207R00000X
ORMD205244207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200944330Medicaid
H81797Medicare UPIN
IN945350026Medicare PIN
NY120AL1Medicare ID - Type Unspecified