Provider Demographics
NPI:1063630150
Name:PEARL, ELIZABETH ANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:ANNE
Last Name:PEARL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ELIZABETH
Other - Middle Name:MILLER
Other - Last Name:PEARL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:7037 FREEDOM CT
Mailing Address - Street 2:APT B
Mailing Address - City:SUMMERSET
Mailing Address - State:SD
Mailing Address - Zip Code:57718-8712
Mailing Address - Country:US
Mailing Address - Phone:765-753-0521
Mailing Address - Fax:
Practice Address - Street 1:7037 FREEDOM CT
Practice Address - Street 2:APT B
Practice Address - City:SUMMERSET
Practice Address - State:SD
Practice Address - Zip Code:57718-8712
Practice Address - Country:US
Practice Address - Phone:765-753-0521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038017A208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100228120Medicaid
IN100228120Medicaid