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General NPI Number Information
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NPI Number | 1629098520
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Entity Type | Organization
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Legal Business Name | CHARLES V. ETTARI, M.D., INC.
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Dates
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Enumeration Date | 07/20/2006
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Last Update Date | 03/04/2015
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Provider Practice Location Address
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Address Line | 9834 GENESEE AVE
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City | LA JOLLA
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State | CA
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Zip | 92037-1223
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Country | US
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Telephone | 619-277-9887
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Fax | 801-253-9831
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Provider Business Mailing Address
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Address Line | PO BOX 2216
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City | DEL MAR
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State | CA
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Zip | 92014-1516
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Country | US
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Telephone | 619-277-9887
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Fax | 801-253-9831
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MS. SHELLY LYNN DAUGHERTY
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Credential |
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Telephone | 619-277-9887
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | G16786
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License Number State | CA
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