Healthcare Provider Details

I. General information

NPI: 1174513113
Provider Name (Legal Business Name): BERT CLAIR ELIASON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 E. NIZHONI BLVD.
GALLUP NM
87301-1337
US

IV. Provider business mailing address

4185 LEIGH LANE
ALTA WY
83414
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1000
  • Fax: 505-726-8740
Mailing address:
  • Phone: 801-471-8894
  • Fax: 909-382-4524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036099778
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: