Provider Demographics
NPI:1447226816
Name:ILORETA, ELPIDIONESTOR TABUTOL (MD)
Entity Type:Individual
Prefix:
First Name:ELPIDIONESTOR
Middle Name:TABUTOL
Last Name:ILORETA
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 1:908 N HOWARD AVE
Mailing Address - Street 2:STE 108
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-3556
Mailing Address - Country:US
Mailing Address - Phone:308-381-2224
Mailing Address - Fax:308-381-0793
Practice Address - Street 1:908 N HOWARD AVE
Practice Address - Street 2:STE 108
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-3556
Practice Address - Country:US
Practice Address - Phone:308-381-2224
Practice Address - Fax:308-381-0793
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE20908207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE278394Medicare ID - Type Unspecified
G62749Medicare UPIN