MEDICARE: DR. STACEY LOUISE DAULT DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QS0010X	Sports Medicine (Family Medicine) Physician	006185	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1760775357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STACEY LOUISE DAULT DO

Provider Business Mailing Address
First Line	:	PO BOX 6085
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85246-6085
Country	:	US
Telephone Number	:	480-846-0688
Fax Number	:	480-741-8650

Provider Business Practice Location Address
First Line	:	6139 S RURAL RD STE 102
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85283-2929
Country	:	US
Telephone Number	:	480-846-0688
Fax Number	:	480-741-8650

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2011
Last Update Date	:	05/07/2026

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