Provider Demographics
NPI:1477571008
Name:ELLISON, ROBERT G JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:G
Last Name:ELLISON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:836 PRUDENTIAL DR
Mailing Address - Street 2:SUITE 1405
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8334
Mailing Address - Country:US
Mailing Address - Phone:904-388-7521
Mailing Address - Fax:904-388-3541
Practice Address - Street 1:836 PRUDENTIAL DR
Practice Address - Street 2:SUITE 1405
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8334
Practice Address - Country:US
Practice Address - Phone:904-388-7521
Practice Address - Fax:904-388-3541
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME395562086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD61757Medicare UPIN
FL14190AMedicare ID - Type UnspecifiedPROVIDER