Provider Demographics
NPI:1114037215
Name:MOUNTCASTLE, ELIZABETH ANN (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:MOUNTCASTLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 241627
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36124-1627
Mailing Address - Country:US
Mailing Address - Phone:334-396-1555
Mailing Address - Fax:334-396-9833
Practice Address - Street 1:286 MITYLENE PARK DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-3548
Practice Address - Country:US
Practice Address - Phone:334-396-1555
Practice Address - Fax:334-396-9833
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL00009695207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL631066099OtherTAX#
AL510-82148OtherBLUE CROSS BLUE SHIELD
AL511-30221OtherBCBS
45-3970660OtherFED TAX #
ALCM4358OtherRR MCR
AL528501290Medicaid
AL528501290Medicaid
AL510-82148OtherBLUE CROSS BLUE SHIELD
AL631066099OtherTAX#