Provider Demographics
NPI:1700955390
Name:NOELKE, ELISABETH L (MD, PA)
Entity type:Individual
Prefix:
First Name:ELISABETH
Middle Name:L
Last Name:NOELKE
Suffix:
Gender:F
Credentials:MD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 S ABE ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-6305
Mailing Address - Country:US
Mailing Address - Phone:325-212-9236
Mailing Address - Fax:800-809-9641
Practice Address - Street 1:3501 KNICKERBOCKER RD
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-7610
Practice Address - Country:US
Practice Address - Phone:325-947-6960
Practice Address - Fax:800-809-9641
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2019-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0164208000000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111604802Medicaid
TX8F22613OtherMEDICARE PTAN RENDERING NPI
TX111604802Medicaid