Individual
DR. BERT CLAIR ELIASON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
516 E. NIZHONI BLVD., GALLUP, NM 87301-1337
(505) 722-1000
(505) 726-8740
Mailing address
4185 LEIGH LANE, ALTA, WY 83414
(801) 471-8894
(909) 382-4524
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
036099778
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
036099778
IL STATE LICENSE
IL
05
—
036099778
—
IL
01
—
336060100
IL STATE CTL SUB LICENSE
IL
Enumeration date
10/21/2005
Last updated
03/07/2023
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