Provider Demographics
NPI:1053334375
Name:ELIZ, NATASHA (MD)
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:
Last Name:ELIZ
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 1:4203 BELFORT RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-1463
Mailing Address - Country:US
Mailing Address - Phone:904-296-5688
Mailing Address - Fax:904-296-5699
Practice Address - Street 1:4203 BELFORT RD
Practice Address - Street 2:SUITE 204
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1463
Practice Address - Country:US
Practice Address - Phone:904-296-5688
Practice Address - Fax:904-296-5699
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90460174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270331900Medicaid
FL270331900Medicaid
FL46078ZMedicare ID - Type UnspecifiedMEDICARE NUMBER