Healthcare Provider Details

I. General information

NPI: 1619910544
Provider Name (Legal Business Name): JOHN L ELFERVIG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 01/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 RIDGE LAKE BLVD
MEMPHIS TN
38120-9411
US

IV. Provider business mailing address

825 RIDGE LAKE BLVD
MEMPHIS TN
38120-9411
US

V. Phone/Fax

Practice location:
  • Phone: 901-685-2200
  • Fax: 901-820-2342
Mailing address:
  • Phone: 901-685-2200
  • Fax: 901-820-2342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD009929
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberR4424
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number14866
License Number StateMS
# 4
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number14866
License Number StateMS
# 5
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License NumberR4424
License Number StateAR
# 6
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number9929
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: