Provider Demographics
NPI:1962720615
Name:MASSEY, STACEY RYDER (MD)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:RYDER
Last Name:MASSEY
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 1:1501 KINGS HWY
Mailing Address - Street 2:DEPARTMENT OF MEDICINE
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-675-5915
Mailing Address - Fax:318-675-5948
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:DEPARTMENT OF MEDICINE
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-675-4881
Practice Address - Fax:318-675-5069
Is Sole Proprietor?:No
Enumeration Date:2010-05-05
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.2053382085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2103661Medicaid
LA503969YH54Medicare PIN