Provider Demographics
NPI:1821209370
Name:QUISPE LEVEAU, DOLLY R (MD)
Entity Type:Individual
Prefix:
First Name:DOLLY
Middle Name:R
Last Name:QUISPE LEVEAU
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 1:6610 MUTUAL DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-4236
Mailing Address - Country:US
Mailing Address - Phone:260-484-8830
Mailing Address - Fax:260-483-1911
Practice Address - Street 1:7910 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4159
Practice Address - Country:US
Practice Address - Phone:260-484-8830
Practice Address - Fax:260-843-1911
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA201075207RH0003X, 207RH0000X
IN01072629A207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0088372Medicaid
IN201184930Medicaid
OH0088372Medicaid
IN055770006Medicare PIN