Provider Demographics
NPI:1689643660
Name:STOUDT, MICHELLE L (DO)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:STOUDT
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 1:1321 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16601-3301
Mailing Address - Country:US
Mailing Address - Phone:814-942-2411
Mailing Address - Fax:814-943-6291
Practice Address - Street 1:1321 11TH AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-3301
Practice Address - Country:US
Practice Address - Phone:814-942-2411
Practice Address - Fax:814-943-6291
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS008587L207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017454350004Medicaid
PA0017454350004Medicaid
G90384Medicare UPIN
PA026159Medicare PIN