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General NPI Number Information
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NPI Number | 1447226816
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Entity Type | Individual
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Provider Name | ELPIDIONESTOR TABUTOL ILORETA MD
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Gender | Male
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Dates
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Enumeration Date | 02/27/2006
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Last Update Date | 12/15/2021
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Provider Practice Location Address
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Address Line | 908 N HOWARD AVE STE 108
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City | GRAND ISLAND
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State | NE
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Zip | 68803-3556
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Country | US
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Telephone | 308-381-2224
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Fax | 308-381-0793
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Provider Business Mailing Address
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Address Line | 908 N HOWARD AVE STE 108
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City | GRAND ISLAND
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State | NE
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Zip | 68803-3556
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Country | US
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Telephone | 308-381-2224
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Fax | 308-381-0793
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 20908
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License Number State | NE
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