Healthcare Provider Details

I. General information

NPI: 1700317591
Provider Name (Legal Business Name): JACK ROBERT STACEY III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2017
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 N HIGHWAY 101
SOLANA BEACH CA
92075-1131
US

IV. Provider business mailing address

3865 HIBISCUS CIR
CARLSBAD CA
92008-3380
US

V. Phone/Fax

Practice location:
  • Phone: 858-330-3737
  • Fax: 833-346-0376
Mailing address:
  • Phone: 321-278-3667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA201262
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: