MEDICARE: MR. JOHN DANIEL ELLIOTT D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	2012-0192	NC
2	207QS0010X	Sports Medicine (Family Medicine) Physician	2012-01920	NC

General Provider Information

NPI Number	:	1326039454
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN DANIEL ELLIOTT D.O.

Provider Business Mailing Address
First Line	:	1144 N ROAD ST STE 200
Second Line	:
City	:	ELIZABETH CITY
State	:	NC
Zip	:	27909-3473
Country	:	US
Telephone Number	:	252-384-2360
Fax Number	:	252-384-2359

Provider Business Practice Location Address
First Line	:	1144 N ROAD ST STE 200
Second Line	:
City	:	ELIZABETH CITY
State	:	NC
Zip	:	27909-3473
Country	:	US
Telephone Number	:	252-384-2360
Fax Number	:	252-384-2359

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/28/2005
Last Update Date	:	04/23/2021

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