Provider Demographics
NPI:1619910544
Name:ELFERVIG, JOHN L (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:ELFERVIG
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 1:825 RIDGE LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9411
Mailing Address - Country:US
Mailing Address - Phone:901-685-2200
Mailing Address - Fax:901-820-2342
Practice Address - Street 1:825 RIDGE LAKE BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-9411
Practice Address - Country:US
Practice Address - Phone:901-685-2200
Practice Address - Fax:901-820-2342
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2018-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD009929207W00000X
ARR4424207W00000X, 207WX0107X
MS14866207W00000X, 207WX0107X
TN9929207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP00658339OtherPALMETTO RR MEDICARE
TN180024050OtherPALMETTO RR MEDICARE
MS00115592Medicaid
AR107447001Medicaid
TN3190249Medicaid
MO202004503Medicaid
MO202004503Medicaid
TN3190249Medicaid
MSP00658339OtherPALMETTO RR MEDICARE
MS180000148Medicare PIN