Provider Demographics
NPI:1184708703
Name:ELLIOTT, RICHARD LOWEN (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:LOWEN
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 1:500 SOUTH 11TH AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-232-3480
Mailing Address - Fax:208-233-6585
Practice Address - Street 1:500 SOUTH 11TH AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-232-3480
Practice Address - Fax:208-233-6585
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4909207W00000X
CAGFE9724207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A58984Medicare UPIN