Healthcare Provider Details

I. General information

NPI: 1699188128
Provider Name (Legal Business Name): TRENTON C ELLIOTT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2014
Last Update Date: 04/30/2020
Certification Date: 04/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

659 AUBURN AVE NE STE 156
ATLANTA GA
30312-1976
US

IV. Provider business mailing address

395 CENTRAL PARK PL NE UNIT 640
ATLANTA GA
30312-1260
US

V. Phone/Fax

Practice location:
  • Phone: 404-888-0228
  • Fax: 404-888-0552
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number260031
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number077870
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: