Healthcare Provider Details

I. General information

NPI: 1073675401
Provider Name (Legal Business Name): ELIZABETH TATE DOUGLASS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH TATE DOUGLASS MD

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 12/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 E 12TH ST STE 102
AUSTIN TX
78701-1955
US

IV. Provider business mailing address

1601 RIO GRANDE ST 340
AUSTIN TX
78701-1137
US

V. Phone/Fax

Practice location:
  • Phone: 409-772-2222
  • Fax:
Mailing address:
  • Phone: 512-324-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberJ1975
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: