Provider Demographics
NPI:1013994755
Name:MAHANOR, ELIZABETH A (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:MAHANOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 PLANTATION ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2038
Mailing Address - Country:US
Mailing Address - Phone:508-368-3190
Mailing Address - Fax:508-368-3193
Practice Address - Street 1:123 SUMMER ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1312
Practice Address - Country:US
Practice Address - Phone:508-368-3190
Practice Address - Fax:508-368-3193
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2264772086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
90832OtherFALLON COMMUNITY HEALTH
MAA39481OtherMEDICARE
MA1013994755OtherUNITED HEALTH CARE
MA110041617AMedicaid
MA7480522OtherAETNA
MA494359OtherTUFTS HEALTH PLAN
MAAA44138OtherHARVARD PILGRIM
MA3589507OtherCIGNA HEALTH PLAN
MAJ29570OtherBLUE CROSS BLUE SHIELD OF MA