Provider Demographics
NPI:1902057417
Name:ATHANS, ELIZABETH TATUM (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:TATUM
Last Name:ATHANS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:LATRELLE
Other - Last Name:TATUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 191
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:9145 NARCOOSSEE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-5768
Practice Address - Country:US
Practice Address - Phone:407-243-2040
Practice Address - Fax:407-243-2043
Is Sole Proprietor?:No
Enumeration Date:2008-10-02
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1097486208000000X
FLME109486208D00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003539500Medicaid