Provider Demographics
NPI:1225021777
Name:ETNYRE, ETHAN ROY (MD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:ROY
Last Name:ETNYRE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2050 S BLOSSER RD
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-7310
Mailing Address - Country:US
Mailing Address - Phone:805-361-8028
Mailing Address - Fax:805-361-8097
Practice Address - Street 1:2120 CIENAGA ST
Practice Address - Street 2:
Practice Address - City:OCEANO
Practice Address - State:CA
Practice Address - Zip Code:93445-9016
Practice Address - Country:US
Practice Address - Phone:805-994-2100
Practice Address - Fax:805-994-2197
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG073939207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB207800OtherMEDICARE ID
080142806OtherRAILROAD MEDICARE
CA00G739390OtherBLUE SHIELD OF CALIFORNIA
CA00G739390Medicaid