Provider Demographics
NPI:1922021856
Name:ELISCO, ANTHONY JOHN III (DO)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:JOHN
Last Name:ELISCO
Suffix:III
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 1:4215 JOE RAMSEY BLVD E # 203
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75401-7852
Mailing Address - Country:US
Mailing Address - Phone:903-408-7930
Mailing Address - Fax:903-408-7929
Practice Address - Street 1:4215 JOE RAMSEY BLVD E # 203
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75401-7852
Practice Address - Country:US
Practice Address - Phone:903-408-7930
Practice Address - Fax:903-408-7929
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS007527L208800000X
TXQ9805208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX539307YMPGOtherMEDICARE
TX366443501Medicaid
TX539307YMPGMedicare PIN