Provider Demographics
NPI:1134239056
Name:ELWORTH, ROBERT L (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
Last Name:ELWORTH
Suffix:
Gender:M
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:PO BOX 4046
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4046
Mailing Address - Country:US
Mailing Address - Phone:417-269-5712
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:1423 N JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-1917
Practice Address - Country:US
Practice Address - Phone:417-269-2273
Practice Address - Fax:417-269-8851
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4D87207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
100276OtherBLUE
MO202079133Medicaid
100276OtherBLUE
P00371887Medicare PIN
A02068Medicare UPIN
021195143Medicare PIN
080069669Medicare PIN