Provider Demographics
NPI:1548242282
Name:ELTZROTH, KIMBERLY SUE (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUE
Last Name:ELTZROTH
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 1:441 30TH ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-2807
Mailing Address - Country:US
Mailing Address - Phone:503-325-7800
Mailing Address - Fax:557-077-5848
Practice Address - Street 1:441 30TH ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-2807
Practice Address - Country:US
Practice Address - Phone:503-325-7800
Practice Address - Fax:557-077-5848
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60413278207V00000X
ORMD26767207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR005974Medicaid
OR005974Medicaid
ORH47803Medicare UPIN