Provider Demographics
NPI:1801886171
Name:MARTIN-STOLDT, DEBORAH L (NP)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:L
Last Name:MARTIN-STOLDT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 N EDDY ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2808
Mailing Address - Country:US
Mailing Address - Phone:574-237-9261
Mailing Address - Fax:574-237-9208
Practice Address - Street 1:211 N EDDY ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2808
Practice Address - Country:US
Practice Address - Phone:574-237-9261
Practice Address - Fax:574-237-9208
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001498A363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200423900Medicaid
IN000000559594OtherBCBS
IN000000526715OtherANTHEM BCBS
IN146470SSSSMedicare ID - Type Unspecified
IN250820DMedicare PIN
IN200423900Medicaid