Provider Demographics
NPI:1578556833
Name:BLACK, ELIZABETH LEFFT (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:LEFFT
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:NICOLE
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1271 HIGHLAND AVE STE B
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-2846
Mailing Address - Country:US
Mailing Address - Phone:509-751-5500
Mailing Address - Fax:509-751-1059
Practice Address - Street 1:1271 HIGHLAND AVE STE B
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2846
Practice Address - Country:US
Practice Address - Phone:509-751-5500
Practice Address - Fax:509-751-1059
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9634207Q00000X
WAMD00045393207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAI42779Medicare UPIN
WAG8856302Medicare PIN