Provider Demographics
NPI:1457763161
Name:ELLIOTT, DANIEL WILSON (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:WILSON
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10410 FOREST CREEK DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46239-9532
Mailing Address - Country:US
Mailing Address - Phone:317-965-3541
Mailing Address - Fax:
Practice Address - Street 1:1701 N SENATE BLVD
Practice Address - Street 2:ROOM AG-012
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1239
Practice Address - Country:US
Practice Address - Phone:317-962-3525
Practice Address - Fax:317-963-5394
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-29
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11017608A390200000X
IN01075355A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201233550Medicaid
IN201233550Medicaid