1447226816 NPI number — ELPIDIONESTOR TABUTOL ILORETA MD

Table of content: ELPIDIONESTOR TABUTOL ILORETA MD (NPI 1447226816)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447226816 NPI number — ELPIDIONESTOR TABUTOL ILORETA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ILORETA
Provider First Name:
ELPIDIONESTOR
Provider Middle Name:
TABUTOL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447226816
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
908 N HOWARD AVE
Provider Second Line Business Mailing Address:
STE 108
Provider Business Mailing Address City Name:
GRAND ISLAND
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68803-3556
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-381-2224
Provider Business Mailing Address Fax Number:
308-381-0793

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
908 N HOWARD AVE
Provider Second Line Business Practice Location Address:
STE 108
Provider Business Practice Location Address City Name:
GRAND ISLAND
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68803-3556
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-381-2224
Provider Business Practice Location Address Fax Number:
308-381-0793
Provider Enumeration Date:
02/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  20908 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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