Provider Demographics
NPI:1255510970
Name:ELLIOTT, KATHLEEN MARILYN (MD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARILYN
Last Name:ELLIOTT
Suffix:
Gender:F
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:PO BOX 60516
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0516
Mailing Address - Country:US
Mailing Address - Phone:336-210-7080
Mailing Address - Fax:336-718-9622
Practice Address - Street 1:3333 SILAS CREEK PKWY
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3013
Practice Address - Country:US
Practice Address - Phone:336-210-7080
Practice Address - Fax:336-718-9622
Is Sole Proprietor?:No
Enumeration Date:2007-10-30
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-00982207R00000X, 207RH0000X
NC200800982207RX0202X
NC127497390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program