Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0401X | Family Doctor - Addiction Medicine | R4D87 | MO |
NPI | 1134239056 |
---|---|
Provider Name | Dr. Robert L. Elworth |
First Address | Springfield, MO 65808-4046 |
Second Address | Springfield, MO 65802-1917 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/08/2006 |
Last Update Date | 07/02/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
100276 | BLUE (01) | |
202079133 | (05) | MO |
A02068 | (02) |