Healthcare Provider Details

I. General information

NPI: 1972750446
Provider Name (Legal Business Name): STACEY MACIP RYDER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2008
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 AMBASSADOR CAFFERY PKWY
LAFAYETTE LA
70508-6917
US

IV. Provider business mailing address

1888 HUDSON CIR STE 2
MONROE LA
71201-3547
US

V. Phone/Fax

Practice location:
  • Phone: 337-470-2180
  • Fax: 337-470-2677
Mailing address:
  • Phone: 337-470-2180
  • Fax: 337-470-2677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD.205841
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: