Provider Demographics
NPI:1508864497
Name:LEVA, STACEY COLLEEN (DO)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:COLLEEN
Last Name:LEVA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 E COOLSPRING AVE
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-6312
Mailing Address - Country:US
Mailing Address - Phone:219-879-6531
Mailing Address - Fax:219-872-7869
Practice Address - Street 1:1225 E COOLSPRING AVE
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-6312
Practice Address - Country:US
Practice Address - Phone:219-879-6531
Practice Address - Fax:219-872-7869
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002919207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200811020Medicaid
INI47996Medicare UPIN
IN217230MMMMMedicare PIN