Provider Demographics
NPI:1174513113
Name:ELIASON, BERT CLAIR (MD)
Entity type:Individual
Prefix:DR
First Name:BERT
Middle Name:CLAIR
Last Name:ELIASON
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 1:4185 LEIGH LANE
Mailing Address - Street 2:
Mailing Address - City:ALTA
Mailing Address - State:WY
Mailing Address - Zip Code:83414
Mailing Address - Country:US
Mailing Address - Phone:801-471-8894
Mailing Address - Fax:909-382-4524
Practice Address - Street 1:516 E. NIZHONI BLVD.
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-1337
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:505-726-8740
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036099778207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036099778OtherIL STATE LICENSE
IL336060100OtherIL STATE CTL SUB LICENSE
IL036099778Medicaid
IL036099778Medicaid
ILA89621Medicare UPIN
IL552490Medicare ID - Type UnspecifiedMEDICARE NUMBER