Provider Demographics
NPI:1164843389
Name:O'BRIEN, STACEY A (MD)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:A
Last Name:O'BRIEN
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 1:1240 EAGLES LANDING PKWY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-5170
Mailing Address - Country:US
Mailing Address - Phone:770-389-3855
Mailing Address - Fax:770-474-8078
Practice Address - Street 1:14205 HIGHWAY 92 STE 105
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-7138
Practice Address - Country:US
Practice Address - Phone:678-293-7854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-16
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALL.3872R207Q00000X
GA73828207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine