Healthcare Provider Details

I. General information

NPI: 1952416489
Provider Name (Legal Business Name): STACY PETERSON D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 01/01/2022
Certification Date: 01/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1997 MIAMISBURG CENTERVILLE RD
DAYTON OH
45459-3811
US

IV. Provider business mailing address

4 BOXWOOD LN
BEVERLY MA
01915-1365
US

V. Phone/Fax

Practice location:
  • Phone: 800-514-1494
  • Fax:
Mailing address:
  • Phone: 401-829-7256
  • Fax: 978-774-3400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number34007398
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: