Provider Demographics
NPI:1073558318
Name:ELLIOTT, DOUGLAS E (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:E
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S UNIVERSITY AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5302
Mailing Address - Country:US
Mailing Address - Phone:501-664-3914
Mailing Address - Fax:501-664-5246
Practice Address - Street 1:500 S UNIVERSITY AVE
Practice Address - Street 2:SUITE 600
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5302
Practice Address - Country:US
Practice Address - Phone:501-664-3914
Practice Address - Fax:501-664-5246
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-36472085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200010760AMedicaid
03050014702OtherQUALCHOICE PROVIDER NUM.
AR149708001Medicaid
H82673Medicare UPIN
AR5M523Medicare ID - Type UnspecifiedMEDICARE/ BC/BS INDIV ID