Provider Demographics
NPI:1073675401
Name:DOUGLASS, ELIZABETH TATE (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:TATE
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:TATE
Other - Last Name:DOUGLASS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1601 RIO GRANDE ST
Mailing Address - Street 2:340
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-1137
Mailing Address - Country:US
Mailing Address - Phone:512-324-7000
Mailing Address - Fax:
Practice Address - Street 1:313 E 12TH ST STE 102
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-1955
Practice Address - Country:US
Practice Address - Phone:409-772-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1975207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX86317JOtherBCBS
TX129870508Medicaid
TX129870506Medicaid
TX129870506Medicaid