Provider Demographics
NPI:1043655442
Name:ELLIOTT, MARK A
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10770 N 46TH ST
Mailing Address - Street 2:SUITE A - 400
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33617-3442
Mailing Address - Country:US
Mailing Address - Phone:813-785-9404
Mailing Address - Fax:813-228-2857
Practice Address - Street 1:10770 N 46TH ST
Practice Address - Street 2:SUITE A - 400
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33617-3442
Practice Address - Country:US
Practice Address - Phone:813-785-9404
Practice Address - Fax:813-228-2857
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-30
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator