Provider Demographics
NPI:1548331812
Name:ELISON, VIEDRA V (DPM)
Entity type:Individual
Prefix:DR
First Name:VIEDRA
Middle Name:V
Last Name:ELISON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14823 W BELL RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-7607
Mailing Address - Country:US
Mailing Address - Phone:623-584-5556
Mailing Address - Fax:623-584-0755
Practice Address - Street 1:14823 W BELL RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-7607
Practice Address - Country:US
Practice Address - Phone:623-584-5556
Practice Address - Fax:623-584-0755
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0500213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ274422072OtherTAX ID
AZ6622680001Medicare NSC
AZU74581Medicare UPIN
AZZ71292Medicare PIN