Provider Demographics
NPI:1992755284
Name:MELTZER, ELLIOTT ALLEN (MD)
Entity type:Individual
Prefix:DR
First Name:ELLIOTT
Middle Name:ALLEN
Last Name:MELTZER
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:PO BOX 10488
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0488
Mailing Address - Country:US
Mailing Address - Phone:888-344-9111
Mailing Address - Fax:909-335-7130
Practice Address - Street 1:1850 N RIVERSIDE AVE
Practice Address - Street 2:SUITE 180
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-8071
Practice Address - Country:US
Practice Address - Phone:909-562-0255
Practice Address - Fax:909-421-3034
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC39403207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1992755284Medicaid
CA1740450923Medicaid
CAZZZ43143ZOtherBLUE SHIELD OF CA
CA1740450923Medicaid
CAZZZ43143ZOtherBLUE SHIELD OF CA
CA008057695Medicare PIN