Provider Demographics
NPI:1184724718
Name:ELLIOTT, MARK STEVEN (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:STEVEN
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 1:4612 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39305-1652
Mailing Address - Country:US
Mailing Address - Phone:601-512-0431
Mailing Address - Fax:601-482-5065
Practice Address - Street 1:5002 HIGHWAY 39 N
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-1078
Practice Address - Country:US
Practice Address - Phone:601-880-3850
Practice Address - Fax:601-693-7758
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16268208200000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS240000061Medicaid
MS00120975Medicaid