Provider Demographics
NPI:1609947464
Name:PERTL, URSULA G (MD)
Entity Type:Individual
Prefix:
First Name:URSULA
Middle Name:G
Last Name:PERTL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3605 VISTA WAY
Mailing Address - Street 2:BUILDING B
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-4565
Mailing Address - Country:US
Mailing Address - Phone:760-547-1010
Mailing Address - Fax:760-547-1011
Practice Address - Street 1:3605 VISTA WAY
Practice Address - Street 2:BUILDING B
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4565
Practice Address - Country:US
Practice Address - Phone:760-547-1010
Practice Address - Fax:760-547-1011
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA89997208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A899970Medicaid
CAI34523Medicare UPIN
CA00A899970Medicaid