Provider Demographics
NPI:1336592633
Name:WEBSTER, ELISHA ELYSE (MD)
Entity type:Individual
Prefix:
First Name:ELISHA
Middle Name:ELYSE
Last Name:WEBSTER
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 1:515 S MOORE ST
Mailing Address - Street 2:
Mailing Address - City:BLUE EARTH
Mailing Address - State:MN
Mailing Address - Zip Code:56013-2158
Mailing Address - Country:US
Mailing Address - Phone:507-526-3273
Mailing Address - Fax:507-526-2467
Practice Address - Street 1:515 S MOORE ST
Practice Address - Street 2:
Practice Address - City:BLUE EARTH
Practice Address - State:MN
Practice Address - Zip Code:56013-2158
Practice Address - Country:US
Practice Address - Phone:507-526-3273
Practice Address - Fax:507-526-2467
Is Sole Proprietor?:No
Enumeration Date:2016-07-21
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDRL14238207Q00000X
MN74343207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND12083Medicaid
NDN6252Medicare PIN