Provider Demographics
NPI:1124081245
Name:DUBOSE, ELIZABETH J (MD)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:J
Last Name:DUBOSE
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:PO BOX 1631
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47706-0032
Mailing Address - Country:US
Mailing Address - Phone:844-825-9300
Mailing Address - Fax:775-852-6902
Practice Address - Street 1:798 S WINCHESTER BLVD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2928
Practice Address - Country:US
Practice Address - Phone:408-984-7226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY326762085R0202X
CAG745452085R0001X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1124081245Medicaid