Provider Demographics
NPI:1619751146
Name:DOUGAN, ELISHEBA (MD)
Entity Type:Individual
Prefix:
First Name:ELISHEBA
Middle Name:
Last Name:DOUGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PRIYANKA
Other - Middle Name:
Other - Last Name:KADAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:7141 W CARTER RD
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-7059
Mailing Address - Country:US
Mailing Address - Phone:971-202-8294
Mailing Address - Fax:480-781-4566
Practice Address - Street 1:3935 N 30TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-4608
Practice Address - Country:US
Practice Address - Phone:623-322-6143
Practice Address - Fax:480-781-4566
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ0673103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ091903Medicaid