Provider Demographics
NPI:1689925711
Name:DEAN D ETTINGER MD PC
Entity Type:Organization
Organization Name:DEAN D ETTINGER MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:ETTINGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-458-0660
Mailing Address - Street 1:155 CALLE PORTAL
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2900
Mailing Address - Country:US
Mailing Address - Phone:520-458-0660
Mailing Address - Fax:520-458-9550
Practice Address - Street 1:155 CALLE PORTAL
Practice Address - Street 2:SUITE 200
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2900
Practice Address - Country:US
Practice Address - Phone:520-458-0660
Practice Address - Fax:520-458-9550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-28
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ121422080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty