Healthcare Provider Details

I. General information

NPI: 1073792974
Provider Name (Legal Business Name): STACY WENTWORTH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2007
Last Update Date: 08/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N. ELAM AVENUE
GREENSBORO NC
27403
US

IV. Provider business mailing address

1317 N ELM ST STE. 1B
GREENSBORO NC
27401-1033
US

V. Phone/Fax

Practice location:
  • Phone: 336-832-1100
  • Fax:
Mailing address:
  • Phone: 336-274-9617
  • Fax: 336-482-2177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number2007-00580
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number200700580
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: