Provider Demographics
NPI:1639380769
Name:TARVIN, STACEY ELAINE (MD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:ELAINE
Last Name:TARVIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1026
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1026
Mailing Address - Country:US
Mailing Address - Phone:317-274-1201
Mailing Address - Fax:317-278-9905
Practice Address - Street 1:699 RILEY HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5119
Practice Address - Country:US
Practice Address - Phone:317-274-2172
Practice Address - Fax:317-278-3031
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010643022080P0216X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0216XAllopathic & Osteopathic PhysiciansPediatricsPediatric Rheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201035650Medicaid
IN201035650Medicaid