Basic Information
| Provider Information | |||||||||
| NPI: | 1073675401 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOUGLASS | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | TATE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DOUGLASS | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | TATE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1601 RIO GRANDE ST | ||||||||
| Address2: | 340 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787011137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123247000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 313 E 12TH ST STE 102 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787011955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097722222 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 12/14/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | J1975 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 86317J | 01 | TX | BCBS | OTHER | 129870508 | 05 | TX | MEDICAID | 129870506 | 05 | TX | MEDICAID |