MEDICARE: DR. LEVI A STODOLA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	64656-20	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598170961
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LEVI A STODOLA MD

Provider Business Mailing Address
First Line	:	PO BOX 735044
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60673-5044
Country	:	US
Telephone Number	:	800-326-2250
Fax Number	:

Provider Business Practice Location Address
First Line	:	1565 ALLOUEZ AVE
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54311-5639
Country	:	US
Telephone Number	:	920-468-2400
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2014
Last Update Date	:	10/16/2024

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