Basic Information
| Provider Information | |||||||||
| NPI: | 1235112129 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ETTINGER | ||||||||
| FirstName: | LEE | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 792 | ||||||||
| Address2: | |||||||||
| City: | SHALIMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325790792 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 904 S 4TH ST | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814014226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702522753 | ||||||||
| FaxNumber: | 9702407330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2005 | ||||||||
| LastUpdateDate: | 05/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | ME 0035386 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RP1001X | DR.0062774 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 067872400 | 05 | FL | MEDICAID | 110007848 | 01 | FL | RAILROAD MEDICARE | OTHER |