MEDICARE: KATIE ELLIOTT OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	11078T	TX

General Provider Information

NPI Number	:	1568208569
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATIE ELLIOTT OD

Provider Business Mailing Address
First Line	:	3924 N TARRANT PKWY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-5410
Country	:	US
Telephone Number	:	817-514-2114
Fax Number	:

Provider Business Practice Location Address
First Line	:	3924 N TARRANT PKWY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-5410
Country	:	US
Telephone Number	:	817-514-2114
Fax Number	:	817-514-2150

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2024
Last Update Date	:	03/19/2025

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