=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285667907
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLIAM D. ERTAG, MD P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 720 GOODLETTE RD N SUITE 204
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34102-5656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-430-0800
-----------------------------------------------------
Fax | 239-430-0538
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 720 GOODLETTE RD N SUITE 204
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34102-5656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-430-0800
-----------------------------------------------------
Fax | 239-430-0538
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | KATHLEEN ANN ZARANEK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 239-430-0800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | ME25371
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------