Provider Demographics
NPI:1336235043
Name:FALLUCCO, ELISE MICHELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:ELISE
Middle Name:MICHELLE
Last Name:FALLUCCO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 44008
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-383-1038
Mailing Address - Fax:904-244-3425
Practice Address - Street 1:580 W 8TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6533
Practice Address - Country:US
Practice Address - Phone:904-383-1038
Practice Address - Fax:904-244-3425
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME1098772084P0804X, 2084P0800X
MO20080074462084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry