Provider Demographics
NPI:1003945411
Name:GRETHEL, ERICH J (MD)
Entity Type:Individual
Prefix:
First Name:ERICH
Middle Name:J
Last Name:GRETHEL
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 1:1301 BARBARA JORDAN BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-3077
Mailing Address - Country:US
Mailing Address - Phone:512-708-1234
Mailing Address - Fax:512-708-4567
Practice Address - Street 1:1301 BARBARA JORDAN BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-3077
Practice Address - Country:US
Practice Address - Phone:512-708-1234
Practice Address - Fax:512-708-4567
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83296174400000X
TXN56952086S0120X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
No2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112887805Medicaid