Provider Demographics
NPI:1083690069
Name:LIVINGSTON, ELIZABETH R (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:R
Last Name:LIVINGSTON
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 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:222 N 2ND ST
Practice Address - Street 2:SUITE 111
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6109
Practice Address - Country:US
Practice Address - Phone:208-381-3915
Practice Address - Fax:208-381-3918
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7089208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery