Provider Demographics
NPI:1033772298
Name:IKEBUDU, STACEY (MD)
Entity type:Individual
Prefix:DR
First Name:STACEY
Middle Name:
Last Name:IKEBUDU
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 1:3690 GRANDVIEW PKWY
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35243-3326
Mailing Address - Country:US
Mailing Address - Phone:205-971-5745
Mailing Address - Fax:
Practice Address - Street 1:960 JOE FRANK HARRIS PKWY SE
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-2129
Practice Address - Country:US
Practice Address - Phone:770-382-1530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-15
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL41924207R00000X
GA91580207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine