Basic Information
| Provider Information | |||||||||
| NPI: | 1376521500 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ETSITTY | ||||||||
| FirstName: | EDISON | ||||||||
| MiddleName: | VIRGIL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 465 SAINT MICHAELS DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875057670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059840303 | ||||||||
| FaxNumber: | 5059841116 | ||||||||
| Practice Location | |||||||||
| Address1: | 465 SAINT MICHAELS DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875057670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059840303 | ||||||||
| FaxNumber: | 5059841116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2006 | ||||||||
| LastUpdateDate: | 02/10/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 2002-0299 | NM | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 10003903 | 01 | NM | LOVELACE HEALTH/SALUD | OTHER | 201038402 | 01 | NM | PRESBYTERIAN HEALTH/SALUD | OTHER | 723040 | 05 | AZ | MEDICAID | 160058344 | 01 | RAILROAD MEDICARE | OTHER | NM009C04 | 01 | NM | BC/BS | OTHER | 50733826 | 05 | NM | MEDICAID | PROVP12721 | 01 | MOLINA | OTHER | 850313268020 | 01 | CHAMPUS | OTHER |