Provider Demographics
NPI:1427051184
Name:ERTL, GREGORY A (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:A
Last Name:ERTL
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 1:350 W CATALINA DR
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-8112
Mailing Address - Country:US
Mailing Address - Phone:928-344-0650
Mailing Address - Fax:928-344-3928
Practice Address - Street 1:350 W CATALINA DR
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-8112
Practice Address - Country:US
Practice Address - Phone:928-344-0650
Practice Address - Fax:928-344-3928
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2016-11-30
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
AZ19732174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ60756Medicare PIN
AZE85939Medicare UPIN