Provider Demographics
NPI:1982864179
Name:COULTHARD, STACY LAUREN (MD)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:LAUREN
Last Name:COULTHARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BROOKE ARMY MEDICAL CENTER
Mailing Address - Street 2:3551 ROGER BROOKE DRIVE
Mailing Address - City:JBSA FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4505
Mailing Address - Country:US
Mailing Address - Phone:210-916-5102
Mailing Address - Fax:
Practice Address - Street 1:BROOKE ARMY MEDICAL CENTER
Practice Address - Street 2:3551 ROGER BROOKE DRIVE
Practice Address - City:JBSA FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4505
Practice Address - Country:US
Practice Address - Phone:210-916-5102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101246005207R00000X, 208600000X
PAMD4804892086S0102X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery