Provider Demographics
NPI:1174663884
Name:NELLIGAN, ELIZABETH K (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:K
Last Name:NELLIGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:KN
Other - Last Name:CAVICKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:28 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3654
Mailing Address - Country:US
Mailing Address - Phone:860-358-4820
Mailing Address - Fax:860-358-8661
Practice Address - Street 1:147 WESTBROOK RD
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:CT
Practice Address - Zip Code:06426-1512
Practice Address - Country:US
Practice Address - Phone:860-767-8265
Practice Address - Fax:860-358-8653
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT044749207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1174663884Medicaid
CTD400011095OtherMEDICARE
CTD400011095OtherMEDICARE