Provider Demographics
NPI:1467488791
Name:ZIMMERMAN, STACY C (MD)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:C
Last Name:ZIMMERMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 251420
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72225-1420
Mailing Address - Country:US
Mailing Address - Phone:501-686-8000
Mailing Address - Fax:501-526-5148
Practice Address - Street 1:1125 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-1908
Practice Address - Country:US
Practice Address - Phone:479-713-8701
Practice Address - Fax:479-713-8719
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-3258207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR03090020200OtherQUALCHOICE
AR149638001Medicaid
ARE3258OtherSTATE LICENSE
AR770272601OtherBREASTCARE
AR03090020200OtherQUALCHOICE
AR770272601OtherBREASTCARE
ARH82089Medicare UPIN