Provider Demographics
NPI:1265413207
Name:MAZZACCO, STACEY LOUISE (MD)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:LOUISE
Last Name:MAZZACCO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 HARRISBURG PIKE STE 200
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-2644
Mailing Address - Country:US
Mailing Address - Phone:717-544-3626
Mailing Address - Fax:717-544-3628
Practice Address - Street 1:2104 HARRISBURG PIKE
Practice Address - Street 2:STE 200
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-2644
Practice Address - Country:US
Practice Address - Phone:717-544-3626
Practice Address - Fax:717-544-3628
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD053932L208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0178844Medicaid
PA020048899OtherRAILROAD MEDICARE
PA037436E9HMedicare PIN
H04438Medicare UPIN
PA0178844Medicaid