Provider Demographics
NPI:1851383830
Name:ELLIOTT, GLEN W (OD)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:W
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 1:250 FAME AVE STE 225
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:PA
Mailing Address - Zip Code:17331-1576
Mailing Address - Country:US
Mailing Address - Phone:717-637-1919
Mailing Address - Fax:
Practice Address - Street 1:250 FAME AVE STE 225
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:PA
Practice Address - Zip Code:17331-1576
Practice Address - Country:US
Practice Address - Phone:717-637-1919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000289152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PACG7940OtherRAILROAD MEDICARE
PA0019476550006Medicaid
PA0019476550006Medicaid
PA064401Medicare PIN
PA074737Q5LMedicare PIN