Provider Demographics
NPI:1528065521
Name:SCHULTIS, STEFANIE ALIDA (MD)
Entity type:Individual
Prefix:
First Name:STEFANIE
Middle Name:ALIDA
Last Name:SCHULTIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 LAKEVIEW DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-7509
Mailing Address - Country:US
Mailing Address - Phone:985-898-1940
Mailing Address - Fax:985-893-3427
Practice Address - Street 1:110 LAKEVIEW DR
Practice Address - Street 2:SUITE 100
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-7509
Practice Address - Country:US
Practice Address - Phone:985-898-1940
Practice Address - Fax:985-893-3427
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA018419174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1389579Medicaid
LA721166765OtherTAX ID
LAE09411Medicare UPIN