Provider Demographics
NPI:1568515617
Name:ELLER, MICHEAL A (CST, CFA,LSA)
Entity Type:Individual
Prefix:
First Name:MICHEAL
Middle Name:A
Last Name:ELLER
Suffix:
Gender:M
Credentials:CST, CFA,LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1386 BROAD VALLEY CT
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-6502
Mailing Address - Country:US
Mailing Address - Phone:817-447-3838
Mailing Address - Fax:
Practice Address - Street 1:1386 BROAD VALLEY CT
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-6502
Practice Address - Country:US
Practice Address - Phone:817-447-3838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA0012174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0070JROtherBCBS OF TEXAS PROVIDER ID