Provider Demographics
NPI:1760566434
Name:ELLIOTT, BRIAN EDWARD (OD)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:EDWARD
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 1:6331 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERBANK
Mailing Address - State:CA
Mailing Address - Zip Code:95367-2733
Mailing Address - Country:US
Mailing Address - Phone:209-869-3300
Mailing Address - Fax:209-869-8809
Practice Address - Street 1:6331 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:RIVERBANK
Practice Address - State:CA
Practice Address - Zip Code:95367
Practice Address - Country:US
Practice Address - Phone:209-869-3300
Practice Address - Fax:209-869-8809
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9440T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0094401Medicaid
CA0723780001OtherMEDICARE DME PIN
CAUO6265Medicare UPIN
SD009400Medicare PIN