Basic Information
| Provider Information | |||||||||
| NPI: | 1578507216 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HJERPE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | ELLSWORTH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 72780 COUNTRY CLUB DR | ||||||||
| Address2: | BLDG B- 203 | ||||||||
| City: | RANCHO MIRAGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922704126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7606743847 | ||||||||
| FaxNumber: | 7606743845 | ||||||||
| Practice Location | |||||||||
| Address1: | 45280 SEELEY DR | ||||||||
| Address2: | 1ST FLR / URGENT CARE | ||||||||
| City: | LA QUINTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922536834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7606107210 | ||||||||
| FaxNumber: | 7605640101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 02/25/2016 | ||||||||
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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 | 207Q00000X | G 80101 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G801012 | 05 | CA | MEDICAID |