Provider Demographics
NPI:1083614267
Name:ELLIOTT, DANIEL O III (OD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:O
Last Name:ELLIOTT
Suffix:III
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 1:220 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
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ18001717B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100221940AMedicaid
IN100221940AMedicaid
IN735630Medicare PIN
IN0165320001Medicare NSC
INM400043203Medicare PIN
IN452570001Medicare PIN
INM400042735Medicare PIN
IN410005232Medicare PIN