Provider Demographics
NPI:1346276334
Name:ELLIOTT, ROBERT LARRY (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LARRY
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 1:1600 W. COLLEGE
Mailing Address - Street 2:SUITE 440
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-3584
Mailing Address - Country:US
Mailing Address - Phone:817-481-9480
Mailing Address - Fax:817-481-2723
Practice Address - Street 1:1600 W. COLLEGE
Practice Address - Street 2:SUITE 440
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-3584
Practice Address - Country:US
Practice Address - Phone:817-481-9480
Practice Address - Fax:817-481-2723
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ5314208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00T86FMedicare PIN