Provider Demographics
NPI:1780616979
Name:ELLIOTT, EDWARD ALBERT (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:ALBERT
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3017 SANTA MONICA BLVD
Mailing Address - Street 2:307
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2534
Mailing Address - Country:US
Mailing Address - Phone:310-829-5540
Mailing Address - Fax:310-861-5750
Practice Address - Street 1:3017 SANTA MONICA BLVD
Practice Address - Street 2:STE 307
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2534
Practice Address - Country:US
Practice Address - Phone:310-829-5540
Practice Address - Fax:310-861-5750
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG462992084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G462992Medicaid
CA00G462991Medicaid
CA00G462991Medicaid
CA00G462992Medicaid
A92636Medicare UPIN