Provider Demographics
NPI:1417020884
Name:ELLIOTT, JERRY L (OD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:L
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:10442 LIPPITT AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75218-2251
Mailing Address - Country:US
Mailing Address - Phone:972-840-1776
Mailing Address - Fax:972-840-1886
Practice Address - Street 1:3159 S GARLAND AVE
Practice Address - Street 2:511B
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75041-4000
Practice Address - Country:US
Practice Address - Phone:972-840-1776
Practice Address - Fax:972-840-1886
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2081T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist