Provider Demographics
NPI:1437317260
Name:CLUBB, ELIZABETH A (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:A
Last Name:CLUBB
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 1:4864 BLUEBONNET BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-9644
Mailing Address - Country:US
Mailing Address - Phone:225-766-7771
Mailing Address - Fax:225-766-7995
Practice Address - Street 1:4864 BLUEBONNET BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-9644
Practice Address - Country:US
Practice Address - Phone:225-766-7771
Practice Address - Fax:225-766-7995
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.11291R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1664278Medicaid
LAG11494Medicare UPIN