Provider Demographics
NPI:1982699013
Name:TREGO, STACY (OD)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:
Last Name:TREGO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD
Mailing Address - Street 2:SUITE 520
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3990
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:703-991-0514
Practice Address - Street 1:1525 W W T HARRIS BLVD
Practice Address - Street 2:NC5998 BLDG 1A1
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-8522
Practice Address - Country:US
Practice Address - Phone:704-295-4433
Practice Address - Fax:704-295-4442
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1954152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2473598Medicare ID - Type Unspecified
NCU96735Medicare UPIN