Provider Demographics
NPI:1649579152
Name:DIPROSPERO, ELIZABETH JOSEPHINE (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:JOSEPHINE
Last Name:DIPROSPERO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 416457
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6457
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23 MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:NJ
Practice Address - Zip Code:07059-5611
Practice Address - Country:US
Practice Address - Phone:908-598-7970
Practice Address - Fax:908-322-4989
Is Sole Proprietor?:No
Enumeration Date:2011-03-23
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08809600207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0280119Medicaid
NJ0280119Medicaid