Provider Demographics
NPI:1326081704
Name:STURDEVANT, JOSEPH L (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:L
Last Name:STURDEVANT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 641057
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15264-1057
Mailing Address - Country:US
Mailing Address - Phone:800-655-2656
Mailing Address - Fax:412-822-7411
Practice Address - Street 1:515 MAIN ST
Practice Address - Street 2:
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-1513
Practice Address - Country:US
Practice Address - Phone:716-373-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD428120207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1552882OtherGATEWAY
PA411353OtherUPMC
PA1015984860001Medicaid
OH2655247OtherOH MEDICAL ASSISTANCE
PAP00339483OtherRR MEDICARE
PA1861235OtherBLUE SHIELD
PA00027610101OtherUNIVERA
WV1069667OtherW. VIRGINIA WORKERS COMP
NY02757308OtherNY MEDICAL ASSISTANCE
PA1333544OtherAETNA
PA186463OtherUNISON
PA1333544OtherAETNA
PA1015984860001Medicaid