Provider Demographics
NPI:1629098520
Name:CHARLES V. ETTARI, M.D., INC.
Entity Type:Organization
Organization Name:CHARLES V. ETTARI, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:DAUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-277-9887
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 1:9834 GENESEE AVE
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1223
Practice Address - Country:US
Practice Address - Phone:619-277-9887
Practice Address - Fax:801-253-9831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG167862084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOG167860Medicaid
CAA90450Medicare UPIN
CAG16786Medicare ID - Type UnspecifiedPROVIDER NUMBER