Provider Demographics
NPI:1629092309
Name:TITO, ELIZABETH P (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:P
Last Name:TITO
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 1:121 SOTOYOME ST STE 203
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4822
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:121 SOTOYOME ST STE 203
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4822
Practice Address - Country:US
Practice Address - Phone:707-525-6180
Practice Address - Fax:707-545-1145
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA213256208600000X
CAG148486208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2100746Medicaid
MA2100746Medicaid
MAG84136Medicare UPIN