Provider Demographics
NPI:1740456714
Name:L.EDWARD ELLIOTT, O.D.
Entity type:Organization
Organization Name:L.EDWARD ELLIOTT, O.D.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF OPTOMETRY
Authorized Official - Prefix:MR
Authorized Official - First Name:L
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:209-838-7263
Mailing Address - Street 1:1555 VIKING ST
Mailing Address - Street 2:
Mailing Address - City:ESCALON
Mailing Address - State:CA
Mailing Address - Zip Code:95320-1742
Mailing Address - Country:US
Mailing Address - Phone:209-838-7263
Mailing Address - Fax:209-838-8093
Practice Address - Street 1:1555 VIKING ST
Practice Address - Street 2:
Practice Address - City:ESCALON
Practice Address - State:CA
Practice Address - Zip Code:95320-1742
Practice Address - Country:US
Practice Address - Phone:209-838-7263
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0047161Medicaid
CASD0047160Medicare PIN