Healthcare Provider Details

I. General information

NPI: 1356873723
Provider Name (Legal Business Name): MATTHEW ELLIOTT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 11/01/2024
Certification Date: 11/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 N STATE ST
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-815-1078
  • Fax: 601-815-4770
Mailing address:
  • Phone: 601-815-1078
  • Fax: 601-815-4770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number28188
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: