Provider Demographics
NPI:1225449754
Name:ITANO, ELISE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:MARIE
Last Name:ITANO
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 1:3727 PECOS ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80211-2655
Mailing Address - Country:US
Mailing Address - Phone:210-367-1223
Mailing Address - Fax:
Practice Address - Street 1:2750 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304
Practice Address - Country:US
Practice Address - Phone:303-440-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-19
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00628192081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine