Provider Demographics
NPI:1013953793
Name:ELLIOTT, EDWARD F JR (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:F
Last Name:ELLIOTT
Suffix:JR
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 1:88 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05301-6074
Mailing Address - Country:US
Mailing Address - Phone:802-257-7513
Mailing Address - Fax:
Practice Address - Street 1:17 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-6613
Practice Address - Country:US
Practice Address - Phone:802-257-8820
Practice Address - Fax:802-257-8849
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010294502085R0202X
VT04200084012085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01029450Medicaid
IN01029450Medicaid