Provider Demographics
NPI:1912964495
Name:ELLERTSON, DAVID GARTH SR (MD)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:GARTH
Last Name:ELLERTSON
Suffix:SR
Gender:M
Credentials:MD
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Mailing Address - Street 1:4101 TULLY RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-8980
Mailing Address - Country:US
Mailing Address - Phone:209-524-8346
Mailing Address - Fax:209-524-7723
Practice Address - Street 1:4101 TULLY RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-8980
Practice Address - Country:US
Practice Address - Phone:209-524-8346
Practice Address - Fax:209-524-7723
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2015-02-12
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Provider Licenses
StateLicense IDTaxonomies
CAG179872086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20014578OtherMEDICARE ID
CA00G179870Medicare PIN
CA20014578OtherMEDICARE ID