Provider Demographics
NPI:1730168592
Name:ELLIOTT, WENDELL H (MD)
Entity type:Individual
Prefix:
First Name:WENDELL
Middle Name:H
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:PO BOX 220
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63902-0220
Mailing Address - Country:US
Mailing Address - Phone:573-686-2411
Mailing Address - Fax:573-686-8452
Practice Address - Street 1:686 LESTER ST
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-5025
Practice Address - Country:US
Practice Address - Phone:573-686-2411
Practice Address - Fax:573-686-8452
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5G12207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR113765001Medicaid
080037682OtherTRAVELERS MEDICARE
MO20Z414900Medicaid
080037682OtherTRAVELERS MEDICARE
A11644Medicare UPIN