Healthcare Provider Details

I. General information

NPI: 1124139985
Provider Name (Legal Business Name): ERICA MERRIAM ELLIOTT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 W ALAMEDA ST APT A2
SANTA FE NM
87507-9655
US

IV. Provider business mailing address

2300 W ALAMEDA ST APT A2
SANTA FE NM
87507-9655
US

V. Phone/Fax

Practice location:
  • Phone: 505-471-8531
  • Fax: 505-471-3184
Mailing address:
  • Phone: 505-471-8531
  • Fax: 505-471-3184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number86-036
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: