Provider Demographics
NPI:1255356119
Name:GOTTESFELD, ELLIS J (MD)
Entity type:Individual
Prefix:
First Name:ELLIS
Middle Name:J
Last Name:GOTTESFELD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7730 BOYNTON BEACH BLVD
Mailing Address - Street 2:#4
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33437-6155
Mailing Address - Country:US
Mailing Address - Phone:561-572-0299
Mailing Address - Fax:561-572-2596
Practice Address - Street 1:7730 BOYNTON BEACH BLVD
Practice Address - Street 2:#4
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33437-6155
Practice Address - Country:US
Practice Address - Phone:561-572-0299
Practice Address - Fax:561-572-2596
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME72007207NS0135X, 207ND0101X, 207NP0225X
FLME 72007207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL16103Medicare PIN
FLB65559Medicare UPIN