Provider Demographics
NPI:1326039454
Name:ELLIOTT, JOHN DANIEL (DO)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:DANIEL
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1144 N ROAD ST STE 200
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-3473
Mailing Address - Country:US
Mailing Address - Phone:252-384-2360
Mailing Address - Fax:252-384-2359
Practice Address - Street 1:1144 N ROAD ST STE 200
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3473
Practice Address - Country:US
Practice Address - Phone:252-384-2360
Practice Address - Fax:252-384-2359
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2012-0192207Q00000X
NC2012-01920207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA011040T25Medicare PIN