Provider Demographics
NPI:1124023643
Name:HOLLISTER, DEBRA ANN STUMPF (DO)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:ANN STUMPF
Last Name:HOLLISTER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:STUMPF
Other - Last Name:HOLLISTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:1395 NW 167TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5710
Mailing Address - Country:US
Mailing Address - Phone:504-264-5142
Mailing Address - Fax:504-455-2648
Practice Address - Street 1:3530 HOUMA BLVD STE 300
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006
Practice Address - Country:US
Practice Address - Phone:504-264-5142
Practice Address - Fax:504-455-2648
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-7136-H207Q00000X
LADO.000130207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2195851Medicaid
OH4031301Medicare PIN
OHH23508Medicare UPIN