Provider Demographics
NPI:1508919341
Name:ELIZAGA, TEODORA BALQUIEDRA (MD)
Entity Type:Individual
Prefix:DR
First Name:TEODORA
Middle Name:BALQUIEDRA
Last Name:ELIZAGA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1524 SUNSET BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:STEUBENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43952-1380
Mailing Address - Country:US
Mailing Address - Phone:740-282-5349
Mailing Address - Fax:740-282-5340
Practice Address - Street 1:1524 SUNSET BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:STEUBENVILLE
Practice Address - State:OH
Practice Address - Zip Code:43952-1380
Practice Address - Country:US
Practice Address - Phone:740-282-5349
Practice Address - Fax:740-282-5340
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.037113207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1508919341OtherTYPE I INDIVIDUAL NPI #
OH341191014002OtherMED MUT GROUP NUMBER
OH0432213Medicaid
OH1807015000OtherWV WELFARE PROVIDER #
OH0022513OtherBOX 24K MT STATE BCBS
OH341191014026OtherCARESOURCE PROVIDER #
OHA37113OtherHEALTH PLAN PROVIDER #
OH1346324514OtherTYPE II NPI #
OH000000128366OtherBCBS PROVIDER NUMBER
OHEL 0476101Medicare ID - Type UnspecifiedINDIV.PROVIDER NUMBER
OH000000128366OtherBCBS PROVIDER NUMBER
OH1508919341OtherTYPE I INDIVIDUAL NPI #