Healthcare Provider Details

I. General information

NPI: 1891726527
Provider Name (Legal Business Name): ELLEN VIRGINIA DRAGSTEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 12/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68 MARCO DRIVE SE
DECATUR AL
35603-0000
US

IV. Provider business mailing address

PO BOX 970
RUSSELLVILLE AL
35653-0970
US

V. Phone/Fax

Practice location:
  • Phone: 256-432-2007
  • Fax: 256-432-2010
Mailing address:
  • Phone: 256-332-1631
  • Fax: 256-332-4600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number00020153
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: