MEDICARE: ELPIDIONESTOR TABUTOL ILORETA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	20908	NE

General Provider Information

NPI Number	:	1447226816
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELPIDIONESTOR TABUTOL ILORETA MD

Provider Business Mailing Address
First Line	:	908 N HOWARD AVE
Second Line	:	STE 108
City	:	GRAND ISLAND
State	:	NE
Zip	:	68803-3556
Country	:	US
Telephone Number	:	308-381-2224
Fax Number	:	308-381-0793

Provider Business Practice Location Address
First Line	:	908 N HOWARD AVE
Second Line	:	STE 108
City	:	GRAND ISLAND
State	:	NE
Zip	:	68803-3556
Country	:	US
Telephone Number	:	308-381-2224
Fax Number	:	308-381-0793

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/27/2006
Last Update Date	:	12/15/2021

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