Basic Information
| Provider Information | |||||||||
| NPI: | 1649200403 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIOTT | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | G | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30370 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857510370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207220777 | ||||||||
| FaxNumber: | 5202909713 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 COLONIA DE SALUD | ||||||||
| Address2: | SUITE 200B | ||||||||
| City: | SIERRA VISTA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856352487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204170468 | ||||||||
| FaxNumber: | 5204590526 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 10/22/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 03390 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 445008 | 05 | AZ | MEDICAID | AZ0761240 | 01 | AZ | BCBSAZ | OTHER |