Provider Demographics
NPI:1215463914
Name:PODKOVIK, STACEY EDWIN (DO)
Entity type:Individual
Prefix:DR
First Name:STACEY
Middle Name:EDWIN
Last Name:PODKOVIK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 W GORE ST STE 403
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1049
Mailing Address - Country:US
Mailing Address - Phone:321-841-3050
Mailing Address - Fax:321-843-3570
Practice Address - Street 1:100 W GORE ST STE 403
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1049
Practice Address - Country:US
Practice Address - Phone:321-841-3050
Practice Address - Fax:321-843-3570
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-02
Last Update Date:2025-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A16756207T00000X
FLOS20696207T00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL128226900Medicaid