Healthcare Provider Details

I. General information

NPI: 1366605495
Provider Name (Legal Business Name): ELISHA R GREGGO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELISHA MCKNIGHT MD

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 08/24/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

463380 STATE ROAD 200 UNIT B
YULEE FL
32097
US

IV. Provider business mailing address

705 WELLS RD STE 300
ORANGE PARK FL
32073-2982
US

V. Phone/Fax

Practice location:
  • Phone: 904-448-4700
  • Fax:
Mailing address:
  • Phone: 904-282-6331
  • Fax: 904-282-4117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME131991
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberME131991
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: