Provider Demographics
NPI:1124009634
Name:ELLESTAD, STEPHEN M (DO)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:M
Last Name:ELLESTAD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 MOUND ST
Mailing Address - Street 2:
Mailing Address - City:DECORAH
Mailing Address - State:IA
Mailing Address - Zip Code:52101-1508
Mailing Address - Country:US
Mailing Address - Phone:563-382-0118
Mailing Address - Fax:
Practice Address - Street 1:502 MOUND ST
Practice Address - Street 2:
Practice Address - City:DECORAH
Practice Address - State:IA
Practice Address - Zip Code:52101-1508
Practice Address - Country:US
Practice Address - Phone:563-382-0118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02380207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAE51653Medicare UPIN