Provider Demographics
NPI:1285774166
Name:ELLIOTT, J GRADY (OD)
Entity type:Individual
Prefix:DR
First Name:J GRADY
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3111 MAPLEWOOD AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3906
Mailing Address - Country:US
Mailing Address - Phone:336-765-8130
Mailing Address - Fax:336-765-6403
Practice Address - Street 1:3111 MAPLEWOOD AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3906
Practice Address - Country:US
Practice Address - Phone:336-765-8130
Practice Address - Fax:336-765-6403
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1456152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0112WOtherBCBS
NC0247000001OtherPALMETTO GBA
NC890908BMedicaid
NC890908BMedicaid
NCU36057Medicare UPIN