Provider Demographics
NPI:1366869208
Name:STIVERS, ELIZABETH S (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:S
Last Name:STIVERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 WALLACE AVE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:LEITCHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42754-1479
Mailing Address - Country:US
Mailing Address - Phone:270-259-5641
Mailing Address - Fax:270-259-5309
Practice Address - Street 1:908 WALLACE AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754-1479
Practice Address - Country:US
Practice Address - Phone:270-259-5641
Practice Address - Fax:270-259-5309
Is Sole Proprietor?:No
Enumeration Date:2014-03-27
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY50135208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100360200Medicaid