Healthcare Provider Details

I. General information

NPI: 1972796225
Provider Name (Legal Business Name): ANDREW ELLEFSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2007
Last Update Date: 08/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 ROCKLAND RD
WILMINGTON DE
19803-3607
US

IV. Provider business mailing address

PO BOX 191 PROVIDER ENROLLMENT
ROCKLAND DE
19732-0191
US

V. Phone/Fax

Practice location:
  • Phone: 302-651-4200
  • Fax: 302-651-4945
Mailing address:
  • Phone: 302-651-6212
  • Fax: 302-651-4945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC1-0008424
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD446913
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: