Provider Demographics
NPI:1114967122
Name:ELLIOTT, MARK T (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:T
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
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Mailing Address - Street 1:1621 S MELROSE DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-5401
Mailing Address - Country:US
Mailing Address - Phone:760-598-9200
Mailing Address - Fax:760-598-9202
Practice Address - Street 1:1621 S MELROSE DR
Practice Address - Street 2:SUITE F
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92081-5401
Practice Address - Country:US
Practice Address - Phone:760-598-9200
Practice Address - Fax:760-598-9202
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CADC21313111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC21313OtherSTATE LICENSE NUMBER
CAU37790Medicare UPIN