Basic Information
| Provider Information | |||||||||
| NPI: | 1841234903 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIOTT | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4800 | ||||||||
| Address2: | UNIT 17 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972084800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8886330087 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1700 E 19TH ST | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970583317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412961111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 11/27/2007 | ||||||||
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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 | 207P00000X | MD23633 | OR | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200129 | 01 | WA L & I | OTHER | 226823 | 05 | OR | MEDICAID | 8351322 | 05 | WA | MEDICAID | P00242638 | 01 | RAIL ROAD | OTHER | 8906931 | 01 | WA CRIME VICTIMS | OTHER |