Provider Demographics
NPI:1154380517
Name:EVERSULL, ELIZABETH (MD)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:
Last Name:EVERSULL
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 97
Mailing Address - Street 2:
Mailing Address - City:BOYCE
Mailing Address - State:LA
Mailing Address - Zip Code:71409-0097
Mailing Address - Country:US
Mailing Address - Phone:972-309-2021
Mailing Address - Fax:972-309-2023
Practice Address - Street 1:5944 W PARKER RD
Practice Address - Street 2:#400
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-6421
Practice Address - Country:US
Practice Address - Phone:972-309-2021
Practice Address - Fax:972-309-2023
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5328208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX176702201Medicaid
TX61345Medicare PIN
H56331Medicare UPIN
TX176702201Medicaid