Provider Demographics
NPI:1174500623
Name:ELLIOTT, LAURIE A (MD)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:A
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3531 MARY ADER AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-5896
Mailing Address - Country:US
Mailing Address - Phone:843-556-0608
Mailing Address - Fax:843-763-3997
Practice Address - Street 1:3531 MARY ADER AVE
Practice Address - Street 2:SUITE C
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5896
Practice Address - Country:US
Practice Address - Phone:843-556-0608
Practice Address - Fax:843-763-3997
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2008-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24981207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC249813Medicaid
SC249813Medicaid
SCH99231Medicare UPIN
SC6598Medicare PIN