Provider Demographics
NPI:1588954721
Name:STUP, ELISABETH ANN HEISER (MD)
Entity type:Individual
Prefix:MRS
First Name:ELISABETH
Middle Name:ANN HEISER
Last Name:STUP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:ELISABETH
Other - Middle Name:ANN
Other - Last Name:HEISER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2706 MEDICAL OFFICE PLACE
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534
Mailing Address - Country:US
Mailing Address - Phone:919-734-4736
Mailing Address - Fax:919-580-1017
Practice Address - Street 1:2706 MEDICAL OFFICE PLACE
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534
Practice Address - Country:US
Practice Address - Phone:919-734-4736
Practice Address - Fax:919-580-1017
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2014-00454208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCFH4441123OtherDEA