Provider Demographics
NPI:1780651760
Name:SMITH, STACY R (MD)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:561 SAXONY PL
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-7700
Mailing Address - Country:US
Mailing Address - Phone:760-203-3839
Mailing Address - Fax:760-203-3840
Practice Address - Street 1:561 SAXONY PL
Practice Address - Street 2:SUITE 102
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-7700
Practice Address - Country:US
Practice Address - Phone:760-203-3839
Practice Address - Fax:760-203-3840
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2013-10-29
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Provider Licenses
StateLicense IDTaxonomies
CAG65407207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG65407OtherMEDICAL LICENSE
CAG65407OtherMEDICAL LICENSE
G04257Medicare UPIN