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General NPI Number Information
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NPI Number | 1194677955
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Entity Type | Organization
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Legal Business Name | STACY PETERSEN MEDICAL GROUP, P.C.
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Dates
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Enumeration Date | 02/12/2026
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Last Update Date | 02/12/2026
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Provider Practice Location Address
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Address Line | 4445 MAGNOLIA AVE
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City | RIVERSIDE
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State | CA
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Zip | 92501
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Country | US
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Telephone | 949-991-4172
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Fax | 949-288-0429
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Provider Business Mailing Address
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Address Line | 26791 ALISO CREEK RD # 1018
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City | ALISO VIEJO
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State | CA
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Zip | 92656-2887
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Country | US
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Telephone |
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Fax | 949-288-0429
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Authorized Official
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Title or Position | SECRETARY
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Name | STACY DIFLEY
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Credential | NP
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Telephone | 949-991-4172
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number |
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License Number State |
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