Provider Demographics
NPI:1578665394
Name:TICE, ELIZABETH (DPM)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:
Last Name:TICE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:GONDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1860 CHADWICK DR STE 206
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-3466
Mailing Address - Country:US
Mailing Address - Phone:601-376-2963
Mailing Address - Fax:601-376-2967
Practice Address - Street 1:1860 CHADWICK DR
Practice Address - Street 2:SUITE 106
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-3463
Practice Address - Country:US
Practice Address - Phone:601-376-2963
Practice Address - Fax:601-376-2967
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80188213E00000X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist