Provider Demographics
NPI:1427062660
Name:TOOTELL, ELENA (MD)
Entity type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:TOOTELL
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 333
Mailing Address - Street 2:
Mailing Address - City:SAN QUENTIN
Mailing Address - State:CA
Mailing Address - Zip Code:94964-0333
Mailing Address - Country:US
Mailing Address - Phone:415-721-3511
Mailing Address - Fax:415-721-3512
Practice Address - Street 1:OFFICE OF THE CMO
Practice Address - Street 2:SAN QUENTIN STATE PRISON
Practice Address - City:SAN QUENTIN
Practice Address - State:CA
Practice Address - Zip Code:94964
Practice Address - Country:US
Practice Address - Phone:415-721-3511
Practice Address - Fax:415-721-3512
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87667207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I41134Medicare UPIN