Healthcare Provider Details

I. General information

NPI: 1467738617
Provider Name (Legal Business Name): ADAM STIVALA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2011
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 N FRANKLIN ST STE 401
CHICAGO IL
60654-7212
US

IV. Provider business mailing address

86-260 FARRINGTON HWY
WAIANAE HI
96792-3128
US

V. Phone/Fax

Practice location:
  • Phone: 856-288-9612
  • Fax:
Mailing address:
  • Phone: 808-697-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25MA10502700
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMED-PHYS-LIC-79647
License Number StateMT
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME142842
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA197909
License Number StateCA
# 6
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD-20270
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: