MEDICARE: STEPHEN EUGENE ERTZ DPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist	PD121R	LA

General Provider Information

NPI Number	:	1356321681
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHEN EUGENE ERTZ DPM

Provider Business Mailing Address
First Line	:	9308 MANSFIELD RD
Second Line	:	STE. 100
City	:	SHREVEPORT
State	:	LA
Zip	:	71118-3134
Country	:	US
Telephone Number	:	318-687-6266
Fax Number	:	318-683-1023

Provider Business Practice Location Address
First Line	:	9308 MANSFIELD RD
Second Line	:	STE. 100
City	:	SHREVEPORT
State	:	LA
Zip	:	71118-3134
Country	:	US
Telephone Number	:	318-687-6266
Fax Number	:	318-683-1023

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2006
Last Update Date	:	08/05/2010

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