Provider Demographics
NPI:1063480804
Name:ELLWEIN, GARY EARL (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:EARL
Last Name:ELLWEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 E 17TH ST
Mailing Address - Street 2:STE 230
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6521
Mailing Address - Country:US
Mailing Address - Phone:208-529-9779
Mailing Address - Fax:208-542-2756
Practice Address - Street 1:3100 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7533
Practice Address - Country:US
Practice Address - Phone:208-529-6050
Practice Address - Fax:208-529-7085
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3265207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003682000Medicaid
ID000010003940OtherREGENCE BLUE SHIELD OF ID
ID32625OtherBLUE CROSS OF IDAHO
ID32625OtherBLUE CROSS OF IDAHO
ID1121828Medicare PIN