Provider Demographics
NPI:1053349415
Name:ELLIOTT, MARK WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILLIAM
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7533 HIGHLINE CT
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-8635
Mailing Address - Country:US
Mailing Address - Phone:406-542-8422
Mailing Address - Fax:
Practice Address - Street 1:3205 S RUSSELL ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-8536
Practice Address - Country:US
Practice Address - Phone:406-721-4906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT72262085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Not Answered2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0103389Medicaid
MTF51284Medicare UPIN