Provider Demographics
NPI:1841220225
Name:BOMGAARS, ELISA (MD)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:
Last Name:BOMGAARS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELISA
Other - Middle Name:TSO
Other - Last Name:BOMGAARS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 6423
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85246-6423
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5810 W BEVERLY LN
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-1800
Practice Address - Country:US
Practice Address - Phone:623-312-3000
Practice Address - Fax:623-312-3060
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ47975207RH0003X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ835216Medicaid
AZZ161393Medicare PIN