Basic Information
| Provider Information | |||||||||
| NPI: | 1245546092 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALTOMARE | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | GRACE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DOUGLAS | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | GRACE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2222 N CRAYCROFT RD STE 150 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857122816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5202023488 | ||||||||
| FaxNumber: | 5202023486 | ||||||||
| Practice Location | |||||||||
| Address1: | 2222 N CRAYCROFT RD STE 150 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857122816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5202023488 | ||||||||
| FaxNumber: | 5202023486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2010 | ||||||||
| LastUpdateDate: | 11/13/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 0101252989 | VA | N | Allopathic & Osteopathic Physicians | Pediatrics | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | 57092 | AZ | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1245546092 | 01 | NPI | OTHER | 57092 | 01 | AZ | ARIZONA MEDICAL BOARD | OTHER |