Provider Demographics
NPI:1174207005
Name:ELSTON, ROBERT J
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:ELSTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 CAMELOT DR
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-4718
Mailing Address - Country:US
Mailing Address - Phone:661-476-7796
Mailing Address - Fax:
Practice Address - Street 1:6 HAIRPIN DR
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62026-1000
Practice Address - Country:US
Practice Address - Phone:618-650-5688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041491458390200000X
MO2022007959390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program