Healthcare Provider Details

I. General information

NPI: 1942283700
Provider Name (Legal Business Name): ELIZABETH ANN CLIBURN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2005
Last Update Date: 09/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1721 W YOSEMITE AVE
MANTECA CA
95337-5130
US

IV. Provider business mailing address

4560 WINDING RIVER CIR
STOCKTON CA
95219-6518
US

V. Phone/Fax

Practice location:
  • Phone: 209-824-5051
  • Fax: 209-824-5028
Mailing address:
  • Phone: 209-824-5045
  • Fax: 209-824-5028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02002820A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A8830
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: