Healthcare Provider Details

I. General information

NPI: 1306832639
Provider Name (Legal Business Name): CARLOS A LEVY-ELICEIRI MD PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 10/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 LAKESHORE DR SUITE B
SAINT MARYS GA
31558-3800
US

IV. Provider business mailing address

100 LAKESHORE DR SUITE B
SAINT MARYS GA
31558-3800
US

V. Phone/Fax

Practice location:
  • Phone: 912-882-4254
  • Fax: 812-882-9493
Mailing address:
  • Phone: 912-882-4254
  • Fax: 888-512-9114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number019967
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number019967
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: