Provider Demographics
NPI:1780766592
Name:ELLIOTT, JEFFERY DALE (OD)
Entity type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:DALE
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1139 N HILLS CTR
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-1882
Mailing Address - Country:US
Mailing Address - Phone:580-332-6000
Mailing Address - Fax:580-332-6006
Practice Address - Street 1:1139 N HILLS CTR
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-1882
Practice Address - Country:US
Practice Address - Phone:580-332-6000
Practice Address - Fax:580-332-6006
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2241152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100762790AMedicaid