Provider Demographics
NPI:1629096631
Name:ETTARI, CHARLES VINCENT (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:VINCENT
Last Name:ETTARI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2216
Mailing Address - Street 2:
Mailing Address - City:DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92014-1516
Mailing Address - Country:US
Mailing Address - Phone:619-277-9887
Mailing Address - Fax:801-253-9831
Practice Address - Street 1:9888 GENESEE AVE
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1205
Practice Address - Country:US
Practice Address - Phone:619-277-9887
Practice Address - Fax:801-253-9831
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2019-11-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG167862084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOG 167860Medicaid
CAA90450Medicare UPIN
CAOOG 167860Medicaid