Provider Demographics
NPI:1700831781
Name:GARCIA, ELISA BOMA
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:BOMA
Last Name:GARCIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1237 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2709
Mailing Address - Country:US
Mailing Address - Phone:270-769-6875
Mailing Address - Fax:270-737-9696
Practice Address - Street 1:1237 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2709
Practice Address - Country:US
Practice Address - Phone:270-769-6875
Practice Address - Fax:270-737-9696
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY20007174400000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000050918OtherANTHEM BCBS
KY1050021OtherPASSPORT
KY130012244OtherRAILROAD MEDICARE
KY64200014Medicaid
KY2432753000OtherPASSPORT ADVANTAGE
000000050918OtherANTHEM BCBS
KY64200014Medicaid