Provider Demographics
NPI:1144361486
Name:ELLIOTT, DOUGLAS R (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:R
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 1:407 S WHITE ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:IA
Mailing Address - Zip Code:52641-2262
Mailing Address - Country:US
Mailing Address - Phone:319-385-6166
Mailing Address - Fax:319-385-6597
Practice Address - Street 1:407 S WHITE ST
Practice Address - Street 2:SUITE 103
Practice Address - City:MOUNT PLEASANT
Practice Address - State:IA
Practice Address - Zip Code:52641-2262
Practice Address - Country:US
Practice Address - Phone:319-385-6166
Practice Address - Fax:319-385-6597
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA23933208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA918OtherMIDLANDS CHOICE
IA1037697Medicaid
IA44596OtherWELLMARK
IAP00178712OtherRAILROAD MEDICARE PIN
IAP00178712OtherRAILROAD MEDICARE PIN
IA44596OtherWELLMARK