Provider Demographics
NPI:1407954589
Name:ELSWORTH, RICHARD (DO)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:ELSWORTH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 W COURT ST
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-5004
Mailing Address - Country:US
Mailing Address - Phone:810-767-3220
Mailing Address - Fax:810-767-7969
Practice Address - Street 1:1402 W COURT ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-5004
Practice Address - Country:US
Practice Address - Phone:810-767-3220
Practice Address - Fax:810-767-7969
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009256207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI160B576250OtherBLUE CROSS BLUE SHIELD
MI112647368Medicaid
MI0M89170003Medicare ID - Type Unspecified
MI112647368Medicaid