Provider Demographics
NPI:1356559769
Name:ELLIOTT, VIDA STEVE (OTR)
Entity type:Individual
Prefix:MR
First Name:VIDA
Middle Name:STEVE
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:OTR
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 1735
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78627-1735
Mailing Address - Country:US
Mailing Address - Phone:936-556-2091
Mailing Address - Fax:
Practice Address - Street 1:1407A KEY ST
Practice Address - Street 2:
Practice Address - City:BRENHAM
Practice Address - State:TX
Practice Address - Zip Code:77833-4543
Practice Address - Country:US
Practice Address - Phone:936-556-2091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109331282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital