Provider Demographics
NPI:1891726527
Name:DRAGSTEN, ELLEN VIRGINIA (MD)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:VIRGINIA
Last Name:DRAGSTEN
Suffix:
Gender:F
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 970
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35653-0970
Mailing Address - Country:US
Mailing Address - Phone:256-332-1631
Mailing Address - Fax:256-332-4600
Practice Address - Street 1:68 MARCO DRIVE SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35603-0000
Practice Address - Country:US
Practice Address - Phone:256-432-2007
Practice Address - Fax:256-432-2010
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00020153208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL630102047Medicaid
51525668OtherBLUE CROSS BLUE SHIELD
D99758Medicare UPIN