Provider Demographics
NPI:1235112129
Name:ETTINGER, LEE DAVID (MD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:DAVID
Last Name:ETTINGER
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:PO BOX 792
Mailing Address - Street 2:
Mailing Address - City:SHALIMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579-0792
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:904 S 4TH ST
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-4226
Practice Address - Country:US
Practice Address - Phone:970-252-2753
Practice Address - Fax:970-240-7330
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 0035386207RP1001X
CODR.0062774207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110007848OtherRAILROAD MEDICARE
FL067872400Medicaid