Basic Information
| Provider Information | |||||||||
| NPI: | 1649458795 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | LY | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | DAU | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT 34929 | ||||||||
| Address2: | P.O. 39000 | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941390001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259522828 | ||||||||
| FaxNumber: | 9259522850 | ||||||||
| Practice Location | |||||||||
| Address1: | 2700 GRANT ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CONCORD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945202266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9256742609 | ||||||||
| FaxNumber: | 9256742211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2008 | ||||||||
| LastUpdateDate: | 06/21/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A102438 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00824966 | 01 | CA | RAILROAD MEDICARE | OTHER |