MEDICARE: ELIZABETH LEFFT BLACK 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	M9634	ID
2	207Q00000X	Family Medicine Physician	MD00045393	WA

General Provider Information

NPI Number	:	1578556833
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH LEFFT BLACK MD

Provider Business Mailing Address
First Line	:	1271 HIGHLAND AVE STE B
Second Line	:
City	:	CLARKSTON
State	:	WA
Zip	:	99403-2846
Country	:	US
Telephone Number	:	509-751-5500
Fax Number	:	509-751-1059

Provider Business Practice Location Address
First Line	:	1271 HIGHLAND AVE STE B
Second Line	:
City	:	CLARKSTON
State	:	WA
Zip	:	99403-2846
Country	:	US
Telephone Number	:	509-751-5500
Fax Number	:	509-751-1059

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

Provider Enumeration Date	:	08/23/2005
Last Update Date	:	03/06/2023

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