Provider Demographics
NPI:1518215672
Name:LIEVANO, ALVARO
Entity Type:Individual
Prefix:
First Name:ALVARO
Middle Name:
Last Name:LIEVANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ALVARO
Other - Middle Name:
Other - Last Name:LIEVANO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3109 BRANDY STA SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-4407
Mailing Address - Country:US
Mailing Address - Phone:770-438-7575
Mailing Address - Fax:770-438-7514
Practice Address - Street 1:3109 BRANDY STA SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-4407
Practice Address - Country:US
Practice Address - Phone:770-438-7575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-21
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA14775174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist