Provider Demographics
NPI:1356485767
Name:SUGDEN, ELIZABETH HART (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:HART
Last Name:SUGDEN
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 587
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303-0587
Mailing Address - Country:US
Mailing Address - Phone:208-814-7400
Mailing Address - Fax:208-814-7491
Practice Address - Street 1:132 5TH AVE W
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-1825
Practice Address - Country:US
Practice Address - Phone:208-324-5286
Practice Address - Fax:208-324-9815
Is Sole Proprietor?:No
Enumeration Date:2007-02-18
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5431207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID820227163G013OtherTRICARE
ID000010001456OtherBLUE SHIELD OF IDAHO
ID080064467OtherMEDICARE RAILROAD
ID820227163B002OtherTRICARE
ID1120618OtherSTATE INSURANCE FUND
ID54312OtherBLUE CROSS OF IDAHO
ID000010142921OtherBLUE SHIELD OF IDAHO
ID003943200Medicaid
ID820227163B002OtherTRI CARE
IDJ8499OtherBLUE CROSS OF IDAHO
IDD48993Medicare UPIN
ID1372609Medicare Oscar/Certification
ID000010001456OtherBLUE SHIELD OF IDAHO
ID820227163G013OtherTRICARE