Provider Demographics
NPI:1669450151
Name:ELLIOTT, ROBERT E (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:E
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 1:2722 OLD MILL DR
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-1320
Mailing Address - Country:US
Mailing Address - Phone:262-632-2020
Mailing Address - Fax:262-632-7085
Practice Address - Street 1:2722 OLD MILL DR
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405-1320
Practice Address - Country:US
Practice Address - Phone:262-632-2020
Practice Address - Fax:262-632-7085
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2658152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38620900Medicaid
WI38620900Medicaid
U43984Medicare UPIN