Provider Demographics
NPI:1528017084
Name:ELLIOTT, CLINT EVERETT (MD)
Entity Type:Individual
Prefix:
First Name:CLINT
Middle Name:EVERETT
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 1:1514 JEFFERSON HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:1514 JEFFERSON HIGHWAY
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70121
Practice Address - Country:US
Practice Address - Phone:504-842-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD200494207L00000X
LAMD.200494207L00000X
IA36697207L00000X
FLME98633207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA24014OtherWELLMARK BCBS
FL278323100Medicaid
MS05353549Medicaid
LA1049930Medicaid
IA0727586Medicaid
IA24014OtherWELLMARK BCBS
LA4M4497061Medicare PIN
LA1049930Medicaid
FL278323100Medicaid
IA0727586Medicaid