Provider Demographics
NPI:1588642276
Name:ELLIOTT, RUSSELL PRICE (OD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:PRICE
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 E WASHINGTON ST
Mailing Address - Street 2:PO BOX 565
Mailing Address - City:GREENCASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:46135-1511
Mailing Address - Country:US
Mailing Address - Phone:765-653-3914
Mailing Address - Fax:765-653-7237
Practice Address - Street 1:125 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GREENCASTLE
Practice Address - State:IN
Practice Address - Zip Code:46135-1511
Practice Address - Country:US
Practice Address - Phone:765-653-3914
Practice Address - Fax:765-653-7237
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001535A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100276770Medicaid
IN954210Medicare ID - Type Unspecified
IN0334910001Medicare NSC
IN100276770Medicaid