Healthcare Provider Details

I. General information

NPI: 1780879239
Provider Name (Legal Business Name): STACEY ELLIS EPSTEIN M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2007
Last Update Date: 10/20/2024
Certification Date: 10/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 ATLANTIC AVE STE 605
LONG BEACH CA
90813-3414
US

IV. Provider business mailing address

1045 ATLANTIC AVE STE 605
LONG BEACH CA
90813-3414
US

V. Phone/Fax

Practice location:
  • Phone: 562-901-6767
  • Fax: 562-901-6777
Mailing address:
  • Phone: 562-901-6767
  • Fax: 562-901-6777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number67121
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: