Provider Demographics
NPI:1356321681
Name:ERTZ, STEPHEN EUGENE (DPM)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:EUGENE
Last Name:ERTZ
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9308 MANSFIELD RD
Mailing Address - Street 2:STE. 100
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3134
Mailing Address - Country:US
Mailing Address - Phone:318-687-6266
Mailing Address - Fax:318-683-1023
Practice Address - Street 1:9308 MANSFIELD RD
Practice Address - Street 2:STE. 100
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3134
Practice Address - Country:US
Practice Address - Phone:318-687-6266
Practice Address - Fax:318-683-1023
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPD121R213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5S654Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER