Provider Demographics
NPI:1568528628
Name:ELLIOTT, PAUL E (LICENSED OPTICIAN)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:E
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:LICENSED OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:561 DAL HALL BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:FL
Mailing Address - Zip Code:33852-5446
Mailing Address - Country:US
Mailing Address - Phone:863-465-1777
Mailing Address - Fax:863-465-5279
Practice Address - Street 1:561 DAL HALL BLVD
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:FL
Practice Address - Zip Code:33852-5446
Practice Address - Country:US
Practice Address - Phone:863-465-1777
Practice Address - Fax:863-465-5279
Is Sole Proprietor?:No
Enumeration Date:2006-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL676156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0709150001Medicare ID - Type UnspecifiedPROVIDER NUMBER