Provider Demographics
NPI:1780781609
Name:EKHOLM, ROBERTA ASHLEY (DO)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:ASHLEY
Last Name:EKHOLM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 CLYDE MORRIS BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5909
Mailing Address - Country:US
Mailing Address - Phone:386-317-8620
Mailing Address - Fax:386-317-8625
Practice Address - Street 1:300 CLYDE MORRIS BLVD STE A
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5909
Practice Address - Country:US
Practice Address - Phone:386-317-8620
Practice Address - Fax:386-317-8625
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS14892207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORE38870Medicare UPIN