Provider Demographics
NPI:1548435365
Name:KACIUBAN, STACEY (MD)
Entity type:Individual
Prefix:DR
First Name:STACEY
Middle Name:
Last Name:KACIUBAN
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 1:110 N FEDERAL HWY
Mailing Address - Street 2:UNIT 914
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-1180
Mailing Address - Country:US
Mailing Address - Phone:954-591-2224
Mailing Address - Fax:
Practice Address - Street 1:1600 S ANDREWS AVE
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2510
Practice Address - Country:US
Practice Address - Phone:954-355-4400
Practice Address - Fax:954-468-8035
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-23
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME102063207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000235600Medicaid
FL91683OtherBCBS
AM087ZMedicare PIN
FL000235600Medicaid