Provider Demographics
NPI:1427097583
Name:ELLIOTT, PHILLIP KEITH (OD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:KEITH
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:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:SNOHOMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98291-0189
Mailing Address - Country:US
Mailing Address - Phone:360-568-1551
Mailing Address - Fax:360-568-9487
Practice Address - Street 1:629 AVENUE D
Practice Address - Street 2:
Practice Address - City:SNOHOMISH
Practice Address - State:WA
Practice Address - Zip Code:98290-2330
Practice Address - Country:US
Practice Address - Phone:360-568-1551
Practice Address - Fax:360-568-9487
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA872152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2254803Medicaid
WAT02982Medicare UPIN