Provider Demographics
NPI:1710955067
Name:SACKETT, ELLEN C (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:C
Last Name:SACKETT
Suffix:
Gender:F
Credentials:MD
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 40767
Mailing Address - Street 2:CREDENTIALING DEPARTMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32203-0767
Mailing Address - Country:US
Mailing Address - Phone:904-376-3707
Mailing Address - Fax:904-391-5807
Practice Address - Street 1:6142 COLLINS RD
Practice Address - Street 2:CREDENTIALING DEPARTMENT
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32244-5806
Practice Address - Country:US
Practice Address - Phone:904-778-3200
Practice Address - Fax:904-778-9835
Is Sole Proprietor?:No
Enumeration Date:2006-03-11
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME54002207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E21367Medicare UPIN
FL07579AMedicare PIN