Provider Demographics
NPI:1174688097
Name:ELLIOTT, JAMES WILLIAM (OD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:WILLIAM
Last Name:ELLIOTT
Suffix:
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 1:12504 U.S. 60
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41102
Mailing Address - Country:US
Mailing Address - Phone:606-929-9432
Mailing Address - Fax:606-929-9622
Practice Address - Street 1:10736 LAUREL RIDGE RD
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41102-8615
Practice Address - Country:US
Practice Address - Phone:606-929-9432
Practice Address - Fax:606-929-9622
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY926DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77009264Medicaid
KY77009264Medicaid