Provider Demographics
NPI:1346532918
Name:MATERA, ELIZABETH L (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:L
Last Name:MATERA
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:PO BOX 1268
Mailing Address - Street 2:
Mailing Address - City:OLIVE HILL
Mailing Address - State:KY
Mailing Address - Zip Code:41164-1268
Mailing Address - Country:US
Mailing Address - Phone:606-286-4152
Mailing Address - Fax:606-286-2385
Practice Address - Street 1:155 BRICKLAYER STREET
Practice Address - Street 2:
Practice Address - City:OLIVE HILL
Practice Address - State:KY
Practice Address - Zip Code:41164
Practice Address - Country:US
Practice Address - Phone:606-286-4152
Practice Address - Fax:606-286-2385
Is Sole Proprietor?:No
Enumeration Date:2011-05-13
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY47594207Q00000X
WI58997390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY47594OtherKY MEDICAL LICENSE
KY7100313530Medicaid
KY47594OtherKY MEDICAL LICENSE