Healthcare Provider Details

I. General information

NPI: 1619962636
Provider Name (Legal Business Name): GEORGE L. ETTEL JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 07/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8950 DR MARTIN LUTHER KING ST N SUITE 180
ST PETERSBURG FL
33702-3001
US

IV. Provider business mailing address

8950 DR MARTIN LUTHER KING JR. STREET, NORTH SUITE 180
ST PETERSBURG FL
33702
US

V. Phone/Fax

Practice location:
  • Phone: 727-576-8900
  • Fax: 727-570-9045
Mailing address:
  • Phone: 727-576-8900
  • Fax: 727-570-9045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME44450
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: