Provider Demographics
NPI:1558633461
Name:ELBON, ROBERT R JR
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:R
Last Name:ELBON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 4TH ST
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241-3839
Mailing Address - Country:US
Mailing Address - Phone:304-704-6475
Mailing Address - Fax:
Practice Address - Street 1:228 4TH ST
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-3839
Practice Address - Country:US
Practice Address - Phone:304-704-6475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV163WH0200X163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVV60.4OtherMEDICAID WAIVER PROGRAM