Provider Demographics
NPI:1225018757
Name:STACY, STANLEY R (DO)
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:R
Last Name:STACY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10106 S SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-6775
Mailing Address - Country:US
Mailing Address - Phone:918-230-9164
Mailing Address - Fax:
Practice Address - Street 1:10106 S SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-6775
Practice Address - Country:US
Practice Address - Phone:918-619-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3054208D00000X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100096630AMedicaid
OKOK403629Medicare PIN
F59710Medicare UPIN
OK100096630AMedicaid