Provider Demographics
NPI:1639241383
Name:MENKIN, ELIZABETH SERRELL (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:SERRELL
Last Name:MENKIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:LYNN
Other - Last Name:SERRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4311 THIRD AVENUE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-1407
Mailing Address - Country:US
Mailing Address - Phone:619-688-1600
Mailing Address - Fax:619-278-6140
Practice Address - Street 1:4311 THIRD AVENUE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-1407
Practice Address - Country:US
Practice Address - Phone:619-688-1600
Practice Address - Fax:619-278-6140
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48270207RH0002X, 207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1639241383Medicaid
CABL351XMedicare PIN
F09905Medicare UPIN