Provider Demographics
NPI:1134206360
Name:DE JESUS, ELIZABETH G (MD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:G
Last Name:DE JESUS
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:1596 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4130
Mailing Address - Country:US
Mailing Address - Phone:401-461-5400
Mailing Address - Fax:401-461-9039
Practice Address - Street 1:1596 BROAD ST
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02905-4130
Practice Address - Country:US
Practice Address - Phone:401-461-5400
Practice Address - Fax:401-461-9039
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RIMD10197207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI04-02873OtherUNITED HEALTH CARE
RI9002877Medicaid
RI11649828OtherCAQH ID NUMBER
RI5488229OtherCIGNA
RI406045OtherBLUE CHIP
RI26781OtherBLUE SHIELD
RI3358011OtherAETNA
RI11649828OtherCAQH ID NUMBER
RIHO8779Medicare UPIN