MEDICARE: DR. ELISA M. MONTROSS-LOPEZ MD..

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	C1-0004991	DE

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	080107124	OTHER	DE	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0002	OTHER	DE	CAREFIRST BCBS DC
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	5728537	OTHER	DE	AETNA
5	0420453000	OTHER	DE	AMERIHEALTH
6	60953701	OTHER	DE	CAREFIRST BCBS
7	15RG73	OTHER	DE	BLUE CROSS BLUE SHIELD DE
8	47279	OTHER	DE	PRINCIPAL HEALTHCARE
9	248021	OTHER	DE	MAMSI/UNITED HEALTH CARE

General Provider Information

NPI Number	:	1376536623
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELISA M. MONTROSS-LOPEZ MD..

Provider Business Mailing Address
First Line	:	640 S STATE ST
Second Line	:	742 BUILDING
City	:	DOVER
State	:	DE
Zip	:	19901-3530
Country	:	US
Telephone Number	:	302-674-3970
Fax Number	:	302-672-2350

Provider Business Practice Location Address
First Line	:	630 MULBERRY STREET
Second Line	:
City	:	MILTON
State	:	DE
Zip	:	19968
Country	:	US
Telephone Number	:	302-684-8053
Fax Number	:	302-684-8059

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2005
Last Update Date	:	10/12/2012

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