Provider Demographics
NPI:1053394114
Name:ELIAS, JACK A (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:A
Last Name:ELIAS
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:300 GEORGE ST
Mailing Address - Street 2:6TH FLOOR PO BOX 9805
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-6624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:789 HOWARD AVE
Practice Address - Street 2:FITKIN BUILDING - 2ND FLOOR
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1304
Practice Address - Country:US
Practice Address - Phone:203-785-4198
Practice Address - Fax:203-785-3826
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT030931207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001309310Medicaid
CT001309310Medicaid
CT290000211Medicare ID - Type Unspecified