Provider Demographics
NPI:1376521500
Name:ETSITTY, EDISON VIRGIL (MD)
Entity Type:Individual
Prefix:
First Name:EDISON
Middle Name:VIRGIL
Last Name:ETSITTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:465 SAINT MICHAELS DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7670
Mailing Address - Country:US
Mailing Address - Phone:505-984-0303
Mailing Address - Fax:505-984-1116
Practice Address - Street 1:465 SAINT MICHAELS DR
Practice Address - Street 2:SUITE 202
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7670
Practice Address - Country:US
Practice Address - Phone:505-984-0303
Practice Address - Fax:505-984-1116
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2002-0299207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM10003903OtherLOVELACE HEALTH/SALUD
NM201038402OtherPRESBYTERIAN HEALTH/SALUD
AZ723040Medicaid
160058344OtherRAILROAD MEDICARE
NMNM009C04OtherBC/BS
NM50733826Medicaid
PROVP12721OtherMOLINA
850313268020OtherCHAMPUS
PROVP12721OtherMOLINA