Provider Demographics
NPI:1326058918
Name:ELLIOTT, CLYDE E (MD)
Entity Type:Individual
Prefix:DR
First Name:CLYDE
Middle Name:E
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 1:304 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291
Mailing Address - Country:US
Mailing Address - Phone:318-388-4863
Mailing Address - Fax:318-388-1144
Practice Address - Street 1:304 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291
Practice Address - Country:US
Practice Address - Phone:318-388-4863
Practice Address - Fax:318-388-1144
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA010533207Q00000X
LA10533208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
B63114Medicare UPIN
LA51504Medicare PIN