Provider Demographics
NPI:1346217874
Name:MERTZ, JOHN E (MD PHD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:E
Last Name:MERTZ
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 9 AVE S
Mailing Address - Street 2:
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-4238
Mailing Address - Country:US
Mailing Address - Phone:612-227-6312
Mailing Address - Fax:
Practice Address - Street 1:1406 6 AVE N
Practice Address - Street 2:
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-1901
Practice Address - Country:US
Practice Address - Phone:320-255-5657
Practice Address - Fax:320-656-7194
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43425207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H39631Medicare UPIN