Provider Demographics
NPI:1205850336
Name:ELLIOTT, EUGENE D (MD)
Entity Type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:D
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9900 TALBERT AVE
Mailing Address - Street 2:101
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-5153
Mailing Address - Country:US
Mailing Address - Phone:714-241-0646
Mailing Address - Fax:
Practice Address - Street 1:9900 TALBERT AVE
Practice Address - Street 2:101
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-5153
Practice Address - Country:US
Practice Address - Phone:714-241-0646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG03800174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC35837Medicare UPIN
CAG38000Medicare ID - Type UnspecifiedPROVIDER NUMBER