Provider Demographics
NPI:1710012117
Name:HEREFORD, ELIZABETH ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:ANN
Last Name:HEREFORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:27901 BRUELLA RD
Mailing Address - Street 2:
Mailing Address - City:GALT
Mailing Address - State:CA
Mailing Address - Zip Code:95632-8245
Mailing Address - Country:US
Mailing Address - Phone:209-369-9462
Mailing Address - Fax:209-334-9470
Practice Address - Street 1:999 S FAIRMONT AVE STE 220
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5142
Practice Address - Country:US
Practice Address - Phone:209-334-9462
Practice Address - Fax:209-334-9470
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00G53434207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G53434OtherMEDICARE
CAA52522OtherUPIN