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NPI Code Detail

MEDICARE: DAVID GARTH ELLERTSON JR. MD

MEDICARE: DAVID GARTH ELLERTSON JR. 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
1208600000XSurgery Physician2005-01291NC

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1588657258
Entity Type Code : Individual
Provider Name (Legal Business Name) : DAVID GARTH ELLERTSON JR. MD
Provider Business Mailing Address
First Line : PO BOX 744786
Second Line :
City : ATLANTA
State : GA
Zip : 30374-4786
Country : US
Telephone Number : 704-834-2450
Fax Number : 704-671-5331
Provider Business Practice Location Address
First Line : 2555 COURT DR STE 450
Second Line :
City : GASTONIA
State : NC
Zip : 28054-2191
Country : US
Telephone Number : 704-671-7652
Fax Number : 704-671-7656
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/26/2005
Last Update Date : 01/27/2020

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