Provider Demographics
NPI:1013187996
Name:DANIEL O. ELLIOTT III OD
Entity Type:Organization
Organization Name:DANIEL O. ELLIOTT III OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:O
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:III
Authorized Official - Credentials:OD
Authorized Official - Phone:574-233-3617
Mailing Address - Street 1:220 N IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46615-2518
Mailing Address - Country:US
Mailing Address - Phone:574-233-3617
Mailing Address - Fax:574-280-7355
Practice Address - Street 1:220 N IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-2518
Practice Address - Country:US
Practice Address - Phone:574-233-3617
Practice Address - Fax:574-280-7355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100221940AMedicaid
IN0165320001Medicare NSC
IN100221940AMedicaid