Provider Demographics
NPI:1619976453
Name:ETTINGER, DAVID J (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:ETTINGER
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 1:3359 KEMP RD
Mailing Address - Street 2:STE. 200
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-2565
Mailing Address - Country:US
Mailing Address - Phone:937-429-7307
Mailing Address - Fax:937-429-7320
Practice Address - Street 1:3359 KEMP RD
Practice Address - Street 2:STE. 200
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-2565
Practice Address - Country:US
Practice Address - Phone:937-429-7307
Practice Address - Fax:937-429-7320
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35064602208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0918243Medicaid
OH240004305OtherRAILROAD MEDICARE
OH000000011941OtherANTHEM
OH240004305OtherRAILROAD MEDICARE
D55187Medicare UPIN
OHH368960Medicare PIN
OH0918243Medicaid