Provider Demographics
NPI:1578826889
Name:ELLIOTT, DUSTIN (MD)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
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 1:34TH & CIVIC CENTER BLVD
Mailing Address - Street 2:9NW55, MAIN HOSPITAL
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104
Mailing Address - Country:US
Mailing Address - Phone:215-590-1221
Mailing Address - Fax:
Practice Address - Street 1:34TH & CIVIC CENTER BLVD
Practice Address - Street 2:9NW55, MAIN HOSPITAL
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-590-1221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2015-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT202452208000000X
NJ25MA09633600208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics