Provider Demographics
NPI:1083602775
Name:ELWONGER, DAVID MARTIN (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MARTIN
Last Name:ELWONGER
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 1:845 SUN VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:WOODLAND PARK
Mailing Address - State:CO
Mailing Address - Zip Code:80863-7729
Mailing Address - Country:US
Mailing Address - Phone:719-632-1502
Mailing Address - Fax:
Practice Address - Street 1:300 W SOUTH AVE
Practice Address - Street 2:#4708
Practice Address - City:WOODLAND PARK
Practice Address - State:CO
Practice Address - Zip Code:80866-7001
Practice Address - Country:US
Practice Address - Phone:719-632-1502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-07
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO209462084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01209469Medicaid
CO01209469Medicaid
CO28461Medicare UPIN