Provider Demographics
NPI:1164495586
Name:ELISOFON, ROBERT MYRON (MD)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:MYRON
Last Name:ELISOFON
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 1:38 B GROVE ST
Mailing Address - Street 2:RIDGEFIELD PEDIATRIC ASSOCIATES
Mailing Address - City:RIDGEFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06877
Mailing Address - Country:US
Mailing Address - Phone:203-438-9557
Mailing Address - Fax:203-438-7857
Practice Address - Street 1:38 B GROVE ST
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:CT
Practice Address - Zip Code:06877
Practice Address - Country:US
Practice Address - Phone:203-438-9557
Practice Address - Fax:203-438-7857
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT016398208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT00163989Medicaid
B20489Medicare UPIN