Provider Demographics
NPI:1588657258
Name:ELLERTSON, DAVID GARTH JR (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:GARTH
Last Name:ELLERTSON
Suffix:JR
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:PO BOX 744786
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-4786
Mailing Address - Country:US
Mailing Address - Phone:704-834-2450
Mailing Address - Fax:704-671-5331
Practice Address - Street 1:2555 COURT DR STE 450
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2191
Practice Address - Country:US
Practice Address - Phone:704-671-7652
Practice Address - Fax:704-671-7656
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-01291208600000X, 208G00000X
WV25541208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1588657258Medicaid
WVWV3287B441Medicare PIN
WV3810026579Medicaid
WVWV3287B441Medicare PIN