Provider Demographics
NPI:1891802815
Name:MODEL-RYBAKOVA, ELENA (MD)
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:MODEL-RYBAKOVA
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 1:1009 BITTERSWEET BRANCH CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32259-5261
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1370 13TH AVE S
Practice Address - Street 2:STE 216
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3230
Practice Address - Country:US
Practice Address - Phone:904-246-8480
Practice Address - Fax:904-246-8578
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92233208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7682202002OtherCIGNA PAL ID
FL28633OtherBCBS PROVIDER ID
FL7910755OtherAETNA PROVIDER ID