Provider Demographics
NPI:1720016777
Name:ETTINGER, DAVID S (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:S
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:PO BOX 64474
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4474
Mailing Address - Country:US
Mailing Address - Phone:410-955-8964
Mailing Address - Fax:
Practice Address - Street 1:10755 FALLS RD
Practice Address - Street 2:
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-4515
Practice Address - Country:US
Practice Address - Phone:410-583-2970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD17207207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD712511900Medicaid
MDC49195Medicare UPIN
MDKR52MR57Medicare PIN