Provider Demographics
NPI:1427710706
Name:ELLIOTT, GARRETT WILLIAM (OD)
Entity type:Individual
Prefix:DR
First Name:GARRETT
Middle Name:WILLIAM
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 1:7013 N PARK RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:RIVERBANK
Mailing Address - State:CA
Mailing Address - Zip Code:95367-9654
Mailing Address - Country:US
Mailing Address - Phone:209-606-5167
Mailing Address - Fax:
Practice Address - Street 1:3601 COFFEE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-1161
Practice Address - Country:US
Practice Address - Phone:209-521-1028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-13
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35043152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist