Provider Demographics
NPI:1164547006
Name:HEADLEY, ELWOOD J (MD)
Entity Type:Individual
Prefix:
First Name:ELWOOD
Middle Name:J
Last Name:HEADLEY
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 1:4525 COVE CIR
Mailing Address - Street 2:# 706
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33708-2883
Mailing Address - Country:US
Mailing Address - Phone:727-391-8996
Mailing Address - Fax:
Practice Address - Street 1:4525 COVE CIR
Practice Address - Street 2:# 706
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33708-2883
Practice Address - Country:US
Practice Address - Phone:727-391-8996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA48890207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine