Provider Demographics
NPI:1811748718
Name:ROMAN, ELLIOTT REED
Entity type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:REED
Last Name:ROMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1629 S 3RD ST APT 202
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40208-1940
Mailing Address - Country:US
Mailing Address - Phone:502-489-1621
Mailing Address - Fax:
Practice Address - Street 1:500 S PRESTON ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1702
Practice Address - Country:US
Practice Address - Phone:502-489-1621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program