Provider Demographics
NPI:1396982500
Name:ELLIOTT, RONALD GLENN (CO/ LO)
Entity type:Individual
Prefix:MR
First Name:RONALD
Middle Name:GLENN
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:CO/ LO
Other - Prefix:
Other - First Name:RONALD
Other - Middle Name:GLENN
Other - Last Name:ELLIOTT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4100 W 3RD ST
Mailing Address - Street 2:4100 WEST THRID STREET
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45428-9000
Mailing Address - Country:US
Mailing Address - Phone:937-268-6511
Mailing Address - Fax:937-267-7623
Practice Address - Street 1:7451 COUNTRY WALK DR
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:OH
Practice Address - Zip Code:45005-7917
Practice Address - Country:US
Practice Address - Phone:513-217-7763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-09
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX231222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH222ZOOOOOXOtherORTHOTIST