Provider Demographics
NPI:1811929466
Name:TRIANA, ELIZABETH ALICE (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ALICE
Last Name:TRIANA
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 1:3155 HARBOR BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-6729
Mailing Address - Country:US
Mailing Address - Phone:941-625-1990
Mailing Address - Fax:941-625-1991
Practice Address - Street 1:3155 HARBOR BLVD STE 100
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-6729
Practice Address - Country:US
Practice Address - Phone:941-625-1990
Practice Address - Fax:941-625-1991
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME46807207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL046316700Medicaid
FLD51998Medicare UPIN
FL08147Medicare ID - Type Unspecified