Provider Demographics
NPI:1649267253
Name:KORN, ELLIOT LAWRENCE (MD)
Entity type:Individual
Prefix:DR
First Name:ELLIOT
Middle Name:LAWRENCE
Last Name:KORN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1715 DEER TRACKS TRL STE 130
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1854
Mailing Address - Country:US
Mailing Address - Phone:314-567-1856
Mailing Address - Fax:314-527-2425
Practice Address - Street 1:1715 DEER TRACKS TRL STE 130
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-1854
Practice Address - Country:US
Practice Address - Phone:314-567-1856
Practice Address - Fax:314-527-2425
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-29
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6E34207WX0200X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202318507Medicaid
MOR51061708OtherBLUE CROSS BLUE SHIELD
MO001013819Medicare ID - Type UnspecifiedMISSOURI AREA 01
MO202318507Medicaid
MO002013820Medicare ID - Type UnspecifiedMISSOURI AREA 99