Provider Demographics
NPI:1871540567
Name:ELLIOTT, CLARK A (MD)
Entity type:Individual
Prefix:
First Name:CLARK
Middle Name:A
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 CASS ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-3236
Mailing Address - Country:US
Mailing Address - Phone:231-941-1155
Mailing Address - Fax:231-259-1005
Practice Address - Street 1:1104 CASS ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-3236
Practice Address - Country:US
Practice Address - Phone:231-941-1155
Practice Address - Fax:231-259-1005
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41717207Y00000X, 207YP0228X
ND12266207Y00000X
NY290496207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I24360Medicare UPIN