Provider Demographics
NPI:1639104169
Name:ELLIOTT, KIRK
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:ARNAUDVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70512-0187
Mailing Address - Country:US
Mailing Address - Phone:337-754-7254
Mailing Address - Fax:337-754-8047
Practice Address - Street 1:410 OLIVE ST
Practice Address - Street 2:
Practice Address - City:ARNAUDVILLE
Practice Address - State:LA
Practice Address - Zip Code:70512-0187
Practice Address - Country:US
Practice Address - Phone:337-754-7254
Practice Address - Fax:337-754-8047
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023075207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1491063Medicaid
LA5Y960Medicare PIN
LA1491063Medicaid
G61863Medicare UPIN
LA5CP69Medicare ID - Type Unspecified