Provider Demographics
NPI:1265749519
Name:CLYDE E. ELLIOTT, M. D. A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:CLYDE E. ELLIOTT, M. D. A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:318-388-4863
Mailing Address - Street 1:304 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-5308
Mailing Address - Country:US
Mailing Address - Phone:318-388-4863
Mailing Address - Fax:318-388-1144
Practice Address - Street 1:304 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-5308
Practice Address - Country:US
Practice Address - Phone:318-388-4863
Practice Address - Fax:318-388-1144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-08
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10533207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAB63114Medicare UPIN