Healthcare Provider Details

I. General information

NPI: 1871532424
Provider Name (Legal Business Name): DAVID L ETTINGER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

992 UNION ST
BANGOR ME
04401-3057
US

IV. Provider business mailing address

PO BOX 1599
BANGOR ME
04402-1599
US

V. Phone/Fax

Practice location:
  • Phone: 207-992-2601
  • Fax:
Mailing address:
  • Phone: 207-404-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD12394
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number12394
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: