Provider Demographics
NPI:1013981042
Name:ELLIOTT, WILLIAM R (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
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 1:1827 RIVA RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44904-2127
Mailing Address - Country:US
Mailing Address - Phone:419-617-4452
Mailing Address - Fax:419-617-1080
Practice Address - Street 1:1827 RIVA RIDGE DR
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44904-2127
Practice Address - Country:US
Practice Address - Phone:419-617-4452
Practice Address - Fax:419-617-1080
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054178207P00000X, 207Q00000X
FLME 89642207P00000X, 207Q00000X
OH35063580207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL277657000Medicaid
GA796583793CMedicaid
OH2016704Medicaid
GA796583793BMedicaid
FL93165OtherBCBS
FLAD739ZMedicare PIN
P00409963Medicare PIN
GAB46580Medicare UPIN
GA796583793BMedicaid
FL277657000Medicaid