Provider Demographics
NPI:1023000502
Name:ELLIOTT, L. EDWARD (OD)
Entity Type:Individual
Prefix:DR
First Name:L.
Middle Name:EDWARD
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 VIKING ST
Mailing Address - Street 2:
Mailing Address - City:ESCALON
Mailing Address - State:CA
Mailing Address - Zip Code:95320-1742
Mailing Address - Country:US
Mailing Address - Phone:209-838-7263
Mailing Address - Fax:209-838-8093
Practice Address - Street 1:1555 VIKING ST
Practice Address - Street 2:
Practice Address - City:ESCALON
Practice Address - State:CA
Practice Address - Zip Code:95320-1742
Practice Address - Country:US
Practice Address - Phone:209-838-7263
Practice Address - Fax:209-838-8093
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4716T152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0047161Medicaid
SD0047160Medicare PIN
CASD0047161Medicaid
CAT09749Medicare UPIN