Provider Demographics
NPI:1992738702
Name:LAFOUNTAIN, ELISA J (DO)
Entity type:Individual
Prefix:
First Name:ELISA
Middle Name:J
Last Name:LAFOUNTAIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:408 N STATE OF FRANKLIN RD
Mailing Address - Street 2:SUITE 24
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6089
Mailing Address - Country:US
Mailing Address - Phone:423-431-1810
Mailing Address - Fax:423-431-1811
Practice Address - Street 1:408 N STATE OF FRANKLIN RD
Practice Address - Street 2:SUITE 24
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6089
Practice Address - Country:US
Practice Address - Phone:423-431-1810
Practice Address - Fax:423-431-1811
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN1788207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP01224653OtherRAILROAD MEDICARE
TN1509060Medicaid
KY7100247440Medicaid
VA1992738702Medicaid
NC1992738702Medicaid
TNP01224653OtherRAILROAD MEDICARE