Provider Demographics
NPI:1497702104
Name:ETTENGER, ALLEN BELO (MD)
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:BELO
Last Name:ETTENGER
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 1:1227 WARM SPRINGS AVE
Mailing Address - Street 2:STE. 301
Mailing Address - City:HUNTINGDON
Mailing Address - State:PA
Mailing Address - Zip Code:16652-2300
Mailing Address - Country:US
Mailing Address - Phone:814-643-8574
Mailing Address - Fax:814-643-8659
Practice Address - Street 1:1227 WARM SPRINGS AVE
Practice Address - Street 2:J. C. BLAIR MEDICAL BUILDING, STE. 301
Practice Address - City:HUNTINGDON
Practice Address - State:PA
Practice Address - Zip Code:16652-2300
Practice Address - Country:US
Practice Address - Phone:814-643-8574
Practice Address - Fax:814-643-8659
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD0332182080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010017640005Medicaid
PA0010017640005Medicaid