Provider Demographics
NPI:1164987749
Name:ELLIOTT, FRED STEVEN
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:STEVEN
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 1:552 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:COSHOCTON
Mailing Address - State:OH
Mailing Address - Zip Code:43812-2358
Mailing Address - Country:US
Mailing Address - Phone:740-575-6564
Mailing Address - Fax:740-722-9008
Practice Address - Street 1:552 WILSON AVE
Practice Address - Street 2:
Practice Address - City:COSHOCTON
Practice Address - State:OH
Practice Address - Zip Code:43812-2358
Practice Address - Country:US
Practice Address - Phone:740-575-6564
Practice Address - Fax:740-722-9008
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-07
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRP532801172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver