=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427051184
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGORY A ERTL MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2005
-----------------------------------------------------
Last Update Date | 11/30/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 350 W CATALINA DR
-----------------------------------------------------
City | YUMA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85364-8112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-344-0650
-----------------------------------------------------
Fax | 928-344-3928
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 350 W CATALINA DR
-----------------------------------------------------
City | YUMA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85364-8112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-344-0650
-----------------------------------------------------
Fax | 928-344-3928
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 19732
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------