Provider Demographics
NPI:1619962636
Name:ETTEL, GEORGE L JR (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:L
Last Name:ETTEL
Suffix:JR
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 1:8950 DR MARTIN LUTHER KING JR. STREET, NORTH
Mailing Address - Street 2:SUITE 180
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702
Mailing Address - Country:US
Mailing Address - Phone:727-576-8900
Mailing Address - Fax:727-570-9045
Practice Address - Street 1:8950 DR MARTIN LUTHER KING ST N
Practice Address - Street 2:SUITE 180
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-3001
Practice Address - Country:US
Practice Address - Phone:727-576-8900
Practice Address - Fax:727-570-9045
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME44450207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL040585000Medicaid
FL040585000Medicaid
FLD57482Medicare UPIN