Basic Information
| Provider Information | |||||||||
| NPI: | 1811257165 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ILES | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ILES | ||||||||
| OtherFirstName: | STACY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DPM | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 714 10TH ST | ||||||||
| Address2: | |||||||||
| City: | SECAUCUS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070942921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2015522256 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 540 37TH ST | ||||||||
| Address2: | |||||||||
| City: | UNION CITY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070872545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018646860 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2012 | ||||||||
| LastUpdateDate: | 10/06/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 25MD00327200 | NJ | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.