Provider Demographics
NPI:1336174903
Name:STOVALL, NICOLE E (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:E
Last Name:STOVALL
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 1:3225 E ELWOOD ST
Mailing Address - Street 2:STE. 110
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85034-7259
Mailing Address - Country:US
Mailing Address - Phone:602-470-5000
Mailing Address - Fax:602-328-2115
Practice Address - Street 1:2601 E ROOSEVELT ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-4973
Practice Address - Country:US
Practice Address - Phone:602-344-1516
Practice Address - Fax:602-344-1004
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD642022085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDM60592OtherCDS #
MDBS8165397OtherFEDERAL DEA
MDM60592OtherCDS #
MDI51430Medicare UPIN