Provider Demographics
NPI:1053422030
Name:ELLIOTT, RANDALL DAVID (OD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:DAVID
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11850 WURZBACH RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-2744
Mailing Address - Country:US
Mailing Address - Phone:210-492-4101
Mailing Address - Fax:210-492-5623
Practice Address - Street 1:11850 WURZBACH RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-2744
Practice Address - Country:US
Practice Address - Phone:210-492-4101
Practice Address - Fax:210-492-5623
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4457TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU20206Medicare UPIN
TX00E68VMedicare ID - Type Unspecified