Provider Demographics
NPI:1205456688
Name:GERDTS, ETHAN ALONSO
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:ALONSO
Last Name:GERDTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9162 REGENTS RD APT C
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1448
Mailing Address - Country:US
Mailing Address - Phone:714-618-2192
Mailing Address - Fax:
Practice Address - Street 1:101 MANNING DR
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-4220
Practice Address - Country:US
Practice Address - Phone:984-974-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-25
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC260936390200000X
CAA185506207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program