Provider Demographics
NPI:1811012545
Name:CAPITOLA PEDIATRICS
Entity Type:Organization
Organization Name:CAPITOLA PEDIATRICS
Other - Org Name:CAPITOLA PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PEDIATRICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BASKERVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:831-475-1883
Mailing Address - Street 1:4145 CLARES STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:CAPITOLA
Mailing Address - State:CA
Mailing Address - Zip Code:95010
Mailing Address - Country:US
Mailing Address - Phone:831-476-1933
Mailing Address - Fax:831-476-2677
Practice Address - Street 1:4145 CLARES STREET
Practice Address - Street 2:SUITE A
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010
Practice Address - Country:US
Practice Address - Phone:831-476-1933
Practice Address - Fax:831-476-2677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0099151Medicaid
CAZZZ08020ZOtherBLUE SHIELD ID#-CAP OFFIC