Provider Demographics
NPI:1750328506
Name:ELLIOTT, KEVIN SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:SCOTT
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:PHYSICIAN SUPPORT SERVICES
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:916-379-2948
Mailing Address - Fax:916-858-7065
Practice Address - Street 1:6555 COYLE AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-0302
Practice Address - Country:US
Practice Address - Phone:916-556-3164
Practice Address - Fax:916-733-5920
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71336207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
00A713360Medicare ID - Type Unspecified
CABJ619UMedicare PIN
I32294Medicare UPIN