Healthcare Provider Details

I. General information

NPI: 1467089888
Provider Name (Legal Business Name): PETER JOHN STACY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2020
Last Update Date: 05/13/2025
Certification Date: 05/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18230 SILVER CREEK STREET BUILDING 392, MDG, SOUTH
BUCKLEY SFB CO
80011
US

IV. Provider business mailing address

5427 EAST MADERA ST BUILDING 4339
DAVIS MONTHAN AFB AZ
85707
US

V. Phone/Fax

Practice location:
  • Phone: 720-847-6451
  • Fax:
Mailing address:
  • Phone: 520-228-4357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2022038659
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: