Provider Demographics
NPI:1760692602
Name:ELIASON, ERIC G (DO)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:G
Last Name:ELIASON
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 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4403 HARRISON BLVD STE 2600
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403
Practice Address - Country:US
Practice Address - Phone:801-387-5620
Practice Address - Fax:801-387-5625
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9082488-1204207RG0100X
WY9455A207RG0100X
CODR.0052667207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY135981900Medicaid
CO87934281Medicaid
WY135981900Medicaid
WYW25935Medicare PIN