Healthcare Provider Details

I. General information

NPI: 1912964495
Provider Name (Legal Business Name): DAVID GARTH ELLERTSON SR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 02/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 TULLY RD SUITE 101
MODESTO CA
95356-8980
US

IV. Provider business mailing address

4101 TULLY RD SUITE 101
MODESTO CA
95356-8980
US

V. Phone/Fax

Practice location:
  • Phone: 209-524-8346
  • Fax: 209-524-7723
Mailing address:
  • Phone: 209-524-8346
  • Fax: 209-524-7723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberG17987
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: