Provider Demographics
NPI:1417156886
Name:OWENS, ELIJAH D (MD)
Entity Type:Individual
Prefix:
First Name:ELIJAH
Middle Name:D
Last Name:OWENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 603898
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3898
Mailing Address - Country:US
Mailing Address - Phone:843-792-6200
Mailing Address - Fax:
Practice Address - Street 1:1594 FREEDOM BLVD
Practice Address - Street 2:SUITE 305
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-6046
Practice Address - Country:US
Practice Address - Phone:843-669-0927
Practice Address - Fax:843-665-9323
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0456352084N0400X
SC342032084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT045635OtherSTATE LICENSE
CT130000679Medicare PIN