Provider Demographics
NPI:1558034538
Name:ELLIOTT, CHARLES
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5110 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:HARAHAN
Mailing Address - State:LA
Mailing Address - Zip Code:70123-5302
Mailing Address - Country:US
Mailing Address - Phone:504-818-1463
Mailing Address - Fax:504-818-2664
Practice Address - Street 1:5110 JEFFERSON HWY
Practice Address - Street 2:
Practice Address - City:HARAHAN
Practice Address - State:LA
Practice Address - Zip Code:70123-5302
Practice Address - Country:US
Practice Address - Phone:504-818-1463
Practice Address - Fax:504-818-2664
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1008-138T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist