Provider Demographics
NPI:1619965977
Name:JACQUES, ELISE A (MD)
Entity Type:Individual
Prefix:DR
First Name:ELISE
Middle Name:A
Last Name:JACQUES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:123 SUMMER ST
Mailing Address - Street 2:SUITE 650
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-1216
Mailing Address - Country:US
Mailing Address - Phone:508-363-9570
Mailing Address - Fax:508-363-9590
Practice Address - Street 1:123 SUMMER ST
Practice Address - Street 2:SUITE 650
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1216
Practice Address - Country:US
Practice Address - Phone:508-363-9570
Practice Address - Fax:508-363-9590
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA37631207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2062925Medicaid
MA2062925Medicaid
B99317Medicare UPIN