Provider Demographics
NPI:1568487684
Name:DONALD, ELYSE MIDORI (MD)
Entity Type:Individual
Prefix:DR
First Name:ELYSE
Middle Name:MIDORI
Last Name:DONALD
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 1:5150 HILL RD E STE B
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-5100
Mailing Address - Country:US
Mailing Address - Phone:707-263-7082
Mailing Address - Fax:
Practice Address - Street 1:5150 HILL RD E STE B
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-5100
Practice Address - Country:US
Practice Address - Phone:707-263-7082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00G770070207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G770070Medicaid
CA00G770070Medicare PIN
CA00G770070Medicaid