Provider Demographics
NPI:1508067273
Name:STAVERS-SOSA, ICELINI (MD)
Entity Type:Individual
Prefix:DR
First Name:ICELINI
Middle Name:
Last Name:STAVERS-SOSA
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 1:1200 CLAY ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-1400
Mailing Address - Country:US
Mailing Address - Phone:813-445-6182
Mailing Address - Fax:
Practice Address - Street 1:1200 CLAY ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-1400
Practice Address - Country:US
Practice Address - Phone:813-445-6182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2705372084P0800X
CA1751512084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03280357Medicaid