Healthcare Provider Details

I. General information

NPI: 1659306157
Provider Name (Legal Business Name): SUSAN TILLMAN ELLIOTT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 01/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4910 MASSACHUSETTS AVE NW SUITE 308
WASHINGTON DC
20016-4300
US

IV. Provider business mailing address

4910 MASSACHUSETTS AVE.,NW SUITE 308
WASHINGTON DC
20016-4382
US

V. Phone/Fax

Practice location:
  • Phone: 202-635-1000
  • Fax: 202-503-1791
Mailing address:
  • Phone: 202-695-1000
  • Fax: 202-503-1791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number0101046205
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD18955
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0101046205
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD18955
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: