Healthcare Provider Details

I. General information

NPI: 1194793430
Provider Name (Legal Business Name): STACIE E ROUGAS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2006
Last Update Date: 07/27/2020
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13301 N MERIDIAN AVE STE 201
OKLAHOMA CITY OK
73120-8381
US

IV. Provider business mailing address

PO BOX 54333
OKLAHOMA CITY OK
73154-1333
US

V. Phone/Fax

Practice location:
  • Phone: 405-803-8020
  • Fax: 405-437-2332
Mailing address:
  • Phone: 405-803-8020
  • Fax: 405-437-2332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number21756
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: