Provider Demographics
NPI:1306832639
Name:LEVY-ELICEIRI, CARLOS A (MD PA)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:A
Last Name:LEVY-ELICEIRI
Suffix:
Gender:M
Credentials:MD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 LAKESHORE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-3800
Mailing Address - Country:US
Mailing Address - Phone:912-882-4254
Mailing Address - Fax:888-512-9114
Practice Address - Street 1:100 LAKESHORE DR
Practice Address - Street 2:SUITE B
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3800
Practice Address - Country:US
Practice Address - Phone:912-882-4254
Practice Address - Fax:812-882-9493
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-22
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA019967208D00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00176272AMedicaid
GA00176272AMedicaid