Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | ME125695 | FL |
NPI | 1003226556 |
---|---|
Provider Name | Richard Luke Elloway |
First Address | Winter Park, FL 32792-3800 |
Second Address | Orlando, FL 32819 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/05/2014 |
Last Update Date | 10/09/2019 |