Provider Demographics
NPI:1144433673
Name:ZAVALA, STACEY RENE (MD)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:RENE
Last Name:ZAVALA
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 1:406 LIPPINCOTT DR STE E
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4168
Mailing Address - Country:US
Mailing Address - Phone:856-983-1900
Mailing Address - Fax:856-893-5110
Practice Address - Street 1:406 LIPPINCOTT DR STE E
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-4168
Practice Address - Country:US
Practice Address - Phone:856-983-1900
Practice Address - Fax:856-983-5110
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10777100207RG0100X
FLME124846207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIG285ZOtherMEDICARE