Provider Demographics
NPI:1588775027
Name:STALLWORTH, LEILA E (MD)
Entity type:Individual
Prefix:
First Name:LEILA
Middle Name:E
Last Name:STALLWORTH
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 1:1499 WALTON WAY
Mailing Address - Street 2:STE 1400
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2602
Mailing Address - Country:US
Mailing Address - Phone:706-724-6100
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-721-2191
Practice Address - Fax:706-721-4920
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043130208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG43130Medicaid
GA000792437AMedicaid
GA37BBFDRMedicare ID - Type Unspecified
SCG43130Medicaid