Provider Demographics
NPI:1154581445
Name:HUMSTON, ELIZABETH G (DO)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:G
Last Name:HUMSTON
Suffix:
Gender:
Credentials:DO
Other - Prefix:DR
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 632476
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-2476
Mailing Address - Country:US
Mailing Address - Phone:423-282-8070
Mailing Address - Fax:423-794-1826
Practice Address - Street 1:303 MED TECH PKWY
Practice Address - Street 2:STE 150
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2391
Practice Address - Country:US
Practice Address - Phone:423-282-8070
Practice Address - Fax:423-794-1826
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2273207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1525142Medicaid