Provider Demographics
NPI:1063479954
Name:ERTEL, LARRY L (MD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:L
Last Name:ERTEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 10TH ST N STE 1D
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-1407
Mailing Address - Country:US
Mailing Address - Phone:727-824-7161
Mailing Address - Fax:727-824-7163
Practice Address - Street 1:620 10TH ST N STE 1D
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1407
Practice Address - Country:US
Practice Address - Phone:727-824-7161
Practice Address - Fax:727-824-7163
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35650207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64012636Medicaid
KYH24943Medicare UPIN
KY0702001Medicare ID - Type Unspecified