Provider Demographics
NPI:1104939503
Name:ELLIOTT, GLEN R (PHD, MD)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:R
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:PHD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 CLARK WAY
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94304-2300
Mailing Address - Country:US
Mailing Address - Phone:650-688-3649
Mailing Address - Fax:650-688-3669
Practice Address - Street 1:650 CLARK WAY
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-2300
Practice Address - Country:US
Practice Address - Phone:650-688-3649
Practice Address - Fax:650-688-3669
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG447412084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G447410Medicaid
CA00G447410Medicaid
CA00G447410Medicare PIN