Provider Demographics
NPI:1457302390
Name:ETTER, ELEGY LEON II (MD)
Entity Type:Individual
Prefix:DR
First Name:ELEGY
Middle Name:LEON
Last Name:ETTER
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:13811 MURPHY RD
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477-4903
Mailing Address - Country:US
Mailing Address - Phone:713-772-1200
Mailing Address - Fax:713-759-0786
Practice Address - Street 1:1315 ST JOSEPH PKWY
Practice Address - Street 2:SUITE 1708
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77002-8233
Practice Address - Country:US
Practice Address - Phone:713-772-1200
Practice Address - Fax:713-759-0786
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3336208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX122872807Medicaid
B22586Medicare UPIN
TX122872807Medicaid