Provider Demographics
NPI:1689655409
Name:EHRHARDT, ELIZABETH A (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:EHRHARDT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-3322
Mailing Address - Country:US
Mailing Address - Phone:719-583-2330
Mailing Address - Fax:719-583-2670
Practice Address - Street 1:1910 LAKE AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3322
Practice Address - Country:US
Practice Address - Phone:719-583-2330
Practice Address - Fax:719-583-2670
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO37792208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO49788817Medicaid
G52458Medicare UPIN