Provider Demographics
NPI:1225063175
Name:ELLIOTT, GERALD W (MD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:W
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 1:120 N EAGLE CREEK DR
Mailing Address - Street 2:SUITE 360
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-1827
Mailing Address - Country:US
Mailing Address - Phone:859-258-5270
Mailing Address - Fax:859-258-5202
Practice Address - Street 1:120 N EAGLE CREEK DR
Practice Address - Street 2:SUITE 360
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1827
Practice Address - Country:US
Practice Address - Phone:859-258-5270
Practice Address - Fax:859-258-5202
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY26524207N00000X, 207NP0225X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYCB5773OtherRAILROAD MEDICARE GROUP
KY37903705OtherMEDICAID LAB GROUP
KY64265242Medicaid
KYASC1019OtherASC MEDICARE GROUP
KY36000818OtherASC MEDICAID LAB GROUP
KY4000501OtherMEDICARE LAB GROUP
KYCB5773OtherRAILROAD MEDICARE GROUP
KY37903705OtherMEDICAID LAB GROUP