Provider Demographics
NPI:1275720682
Name:BALES, ELIZABETH ANDREA (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANDREA
Last Name:BALES
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 1:3226 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-4224
Mailing Address - Country:US
Mailing Address - Phone:949-410-4207
Mailing Address - Fax:
Practice Address - Street 1:3226 BROAD ST
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4224
Practice Address - Country:US
Practice Address - Phone:949-410-4207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-29
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA91889207LC0200X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACM197AMedicare PIN
CACM197ZMedicare PIN