Provider Demographics
NPI:1649200403
Name:ELLIOTT, WILLIAM G (DO)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:G
Last Name:ELLIOTT
Suffix:
Gender:M
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:PO BOX 30370
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85751-0370
Mailing Address - Country:US
Mailing Address - Phone:520-722-0777
Mailing Address - Fax:520-290-9713
Practice Address - Street 1:75 COLONIA DE SALUD
Practice Address - Street 2:SUITE 200B
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2487
Practice Address - Country:US
Practice Address - Phone:520-417-0468
Practice Address - Fax:520-459-0526
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ03390207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ445008Medicaid
AZAZ0761240OtherBCBSAZ
AZZ83130Medicare PIN
AZ445008Medicaid