Provider Demographics
NPI:1700288024
Name:LIGON, ELIZABETH GAULT (OD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:GAULT
Last Name:LIGON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:TN
Mailing Address - Zip Code:38008-2242
Mailing Address - Country:US
Mailing Address - Phone:731-658-5197
Mailing Address - Fax:731-658-5245
Practice Address - Street 1:725 W MARKET ST
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:TN
Practice Address - Zip Code:38008
Practice Address - Country:US
Practice Address - Phone:731-658-5197
Practice Address - Fax:731-658-5197
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-17
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3199152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7699658OtherCIGNA
TNA22476OtherEYEMED
TNQ01027Medicaid
TN48082-001OtherDAVIS VISION
TN6051220OtherBCBSTN