Provider Demographics
NPI:1831171107
Name:LACEY, STUART R (MD)
Entity type:Individual
Prefix:DR
First Name:STUART
Middle Name:R
Last Name:LACEY
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:5310 W THUNDERBIRD RD
Mailing Address - Street 2:SUITE110
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-4706
Mailing Address - Country:US
Mailing Address - Phone:602-865-4065
Mailing Address - Fax:602-865-6100
Practice Address - Street 1:5310 W THUNDERBIRD RD
Practice Address - Street 2:SUITE110
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4706
Practice Address - Country:US
Practice Address - Phone:602-865-4065
Practice Address - Fax:602-865-6100
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2014-02-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ315902086S0120X
ORMD1550682086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ788763Medicaid
AZC85080Medicare UPIN
AZ788763Medicaid