Provider Demographics
NPI:1629490123
Name:ELLIOTT, ANGELA (DO)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1518 MULBERRY AVE
Mailing Address - Street 2:
Mailing Address - City:MUSCATINE
Mailing Address - State:IA
Mailing Address - Zip Code:52761-3433
Mailing Address - Country:US
Mailing Address - Phone:563-264-9508
Mailing Address - Fax:563-264-0166
Practice Address - Street 1:1518 MULBERRY AVE
Practice Address - Street 2:
Practice Address - City:MUSCATINE
Practice Address - State:IA
Practice Address - Zip Code:52761-3433
Practice Address - Country:US
Practice Address - Phone:563-264-9508
Practice Address - Fax:563-264-0166
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-17
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADO-04528207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1982831426Medicaid