Provider Demographics
NPI:1316932031
Name:ELLIOTT, TERRI LEE (DO)
Entity type:Individual
Prefix:DR
First Name:TERRI
Middle Name:LEE
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 BIDARKA ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-7741
Mailing Address - Country:US
Mailing Address - Phone:907-335-0034
Mailing Address - Fax:907-335-0064
Practice Address - Street 1:135 BIDARKA ST
Practice Address - Street 2:SUITE 101
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-7741
Practice Address - Country:US
Practice Address - Phone:907-335-0034
Practice Address - Fax:907-335-0064
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAK4040207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK152262OtherMEDICARE ID
AKAK4040OtherSTATE LICENSE
AK152261OtherMEDICARE GROUP NUMBER
AKMD6089Medicaid
AKMD6089Medicaid
AKG30803Medicare UPIN