Provider Demographics
NPI:1710274642
Name:ROOS, ELICIA D (DO)
Entity type:Individual
Prefix:DR
First Name:ELICIA
Middle Name:D
Last Name:ROOS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 746638
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6638
Mailing Address - Country:US
Mailing Address - Phone:904-202-2022
Mailing Address - Fax:904-376-4075
Practice Address - Street 1:141 HILDEN RD STE 201
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-8400
Practice Address - Country:US
Practice Address - Phone:904-825-1941
Practice Address - Fax:904-390-7460
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS12591207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01366468OtherRAILROAD MEDICARE
FLHW375ZMedicare PIN