Provider Demographics
NPI:1295774081
Name:STOVALL, VICKI MIZUE (MD)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:MIZUE
Last Name:STOVALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 16954
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27516-6954
Mailing Address - Country:US
Mailing Address - Phone:866-497-8330
Mailing Address - Fax:919-967-6647
Practice Address - Street 1:404 WESTWOOD AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-4315
Practice Address - Country:US
Practice Address - Phone:919-882-6500
Practice Address - Fax:919-882-6501
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC38854207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC80204OtherBLUE CROSS/BLUE SHIELD
NC8980204Medicaid
NC80204OtherBLUE CROSS/BLUE SHIELD
NC2151537GMedicare ID - Type Unspecified