Provider Demographics
NPI:1578829826
Name:ELLIOTT, MICHAEL STEVEN (SOIDC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:STEVEN
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:SOIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1ST MARINE SPECIAL OPERATIONS BTN.
Mailing Address - Street 2:CAMP PENDLETON, CA 92055
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:92055
Mailing Address - Country:US
Mailing Address - Phone:509-780-1453
Mailing Address - Fax:
Practice Address - Street 1:1ST MARINE SPECIAL OPERATIONS BTN.
Practice Address - Street 2:BOX 555341
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055-5341
Practice Address - Country:US
Practice Address - Phone:760-725-5298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-11
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10126925ME1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman