Provider Demographics
NPI:1881809218
Name:WOMACK BATZDORF, STACY LORAE (MD)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:LORAE
Last Name:WOMACK BATZDORF
Suffix:
Gender:F
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:TRIFTSTRASSE 10
Mailing Address - Street 2:
Mailing Address - City:MUNICH
Mailing Address - State:BAVARIA
Mailing Address - Zip Code:D 80538
Mailing Address - Country:DE
Mailing Address - Phone:01149892-370-8680
Mailing Address - Fax:
Practice Address - Street 1:3849 VENTURA CANYON
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423
Practice Address - Country:US
Practice Address - Phone:818-905-8005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76108207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH81298Medicare UPIN