Provider Demographics
NPI:1285836858
Name:WETSMAN, ELLIE FOX (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLIE
Middle Name:FOX
Last Name:WETSMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HENRY CLAY AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70118-5720
Mailing Address - Country:US
Mailing Address - Phone:504-896-9236
Mailing Address - Fax:504-894-8744
Practice Address - Street 1:200 HENRY CLAY AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70118-5720
Practice Address - Country:US
Practice Address - Phone:504-896-9236
Practice Address - Fax:504-894-8744
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11725R208000000X, 2080C0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080C0008XAllopathic & Osteopathic PhysiciansPediatricsChild Abuse Pediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1682331Medicaid
LA1682331Medicaid