Provider Demographics
NPI:1922441997
Name:ELLIOTT, MARK DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1348 LA PLAYA ST APT 3
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94122-1099
Mailing Address - Country:US
Mailing Address - Phone:415-727-6766
Mailing Address - Fax:
Practice Address - Street 1:1950 W. CORPORATE WAY
Practice Address - Street 2:PMB 21669
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801
Practice Address - Country:US
Practice Address - Phone:415-727-6766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-09
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA803-A1331482084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program