Healthcare Provider Details

I. General information

NPI: 1093820904
Provider Name (Legal Business Name): STACEY ALLEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 05/26/2020
Certification Date: 05/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 MEDICAL DR
SAN ANTONIO TX
78229-4402
US

IV. Provider business mailing address

4502 MEDICAL DR STE 900
SAN ANTONIO TX
78229-4402
US

V. Phone/Fax

Practice location:
  • Phone: 210-592-0400
  • Fax:
Mailing address:
  • Phone: 210-358-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License NumberJ7743
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberJ7743
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: