Provider Demographics
NPI:1417977042
Name:ELLIOTT-MULLENS, DANETTE RAI (DO)
Entity Type:Individual
Prefix:DR
First Name:DANETTE
Middle Name:RAI
Last Name:ELLIOTT-MULLENS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 MASON RIDGE CENTER DR STE 300
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8512
Mailing Address - Country:US
Mailing Address - Phone:314-448-3791
Mailing Address - Fax:314-996-7658
Practice Address - Street 1:2650 NE COURTNEY DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-7636
Practice Address - Country:US
Practice Address - Phone:541-647-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9775207R00000X, 2080A0000X
ORDO1509432080A0000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143444105Medicaid
TX15402701OtherMEDICAID TPI BILLING NUMBER
MO2023050669OtherMO STATE BOARD OF REGISTRATION
TX8AJ420OtherBCBS INDIV PROV #
OR500621599Medicaid
OR500621599Medicaid
ORR154072Medicare PIN