Provider Demographics
NPI:1427046085
Name:KRILL-JACKSON, ELISA (MD)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:
Last Name:KRILL-JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 NW 12TH AVE FL 32
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1002
Mailing Address - Country:US
Mailing Address - Phone:305-243-5302
Mailing Address - Fax:305-243-9161
Practice Address - Street 1:1475 NW 12TH AVE FL 32
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1002
Practice Address - Country:US
Practice Address - Phone:305-243-5302
Practice Address - Fax:305-243-9161
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0066352207RH0003X
FLME66352174400000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL272074400Medicaid
FLG23547Medicare UPIN
FL28534YMedicare ID - Type Unspecified