Provider Demographics
NPI:1124018056
Name:RICHELSON, ELLIOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLIOTT
Middle Name:
Last Name:RICHELSON
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 1:1300 MARSH LANDING PKWY STE 112
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-2407
Mailing Address - Country:US
Mailing Address - Phone:904-456-0002
Mailing Address - Fax:904-373-0894
Practice Address - Street 1:1300 MARSH LANDING PKWY STE 112
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-2407
Practice Address - Country:US
Practice Address - Phone:904-456-0002
Practice Address - Fax:904-373-0894
Is Sole Proprietor?:No
Enumeration Date:2005-10-22
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN618472084P0800X
CAG1709982084P0800X
WI74291-202084P0800X
MA2859442084P0800X
NHEL107172084P0800X
NC2649362084P0800X
NJ25MA109303002084P0800X
FL1172842084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL700006036OtherRAILROAD MEDICARE
FL09949OtherBLUECROSS/BLUESHIELD
FL700006036OtherRAILROAD MEDICARE
FLD83707Medicare UPIN
FL268589200Medicaid