Provider Demographics
NPI:1790990752
Name:ELLIOTT, BRIAN J (DO)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
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 1:1900 W CHANDLER BLVD STE 15-331
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-6216
Mailing Address - Country:US
Mailing Address - Phone:509-885-6394
Mailing Address - Fax:
Practice Address - Street 1:3920 S ROME ST
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-7366
Practice Address - Country:US
Practice Address - Phone:480-597-4778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-13
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60155531207L00000X
NVDO1412207L00000X
AZ4805207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP01314794OtherRR MEDICARE
WA1790990752Medicaid
WAG8926604, G8926605Medicare PIN