Provider Demographics
NPI:1255366464
Name:ETTINGER, JEFFREY C (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:C
Last Name:ETTINGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2930 2ND AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:MARINA
Mailing Address - State:CA
Mailing Address - Zip Code:93933-6244
Mailing Address - Country:US
Mailing Address - Phone:831-582-2100
Mailing Address - Fax:831-886-1529
Practice Address - Street 1:2930 2ND AVE STE 200
Practice Address - Street 2:
Practice Address - City:MARINA
Practice Address - State:CA
Practice Address - Zip Code:93933
Practice Address - Country:US
Practice Address - Phone:831-582-2100
Practice Address - Fax:831-886-1529
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG57512207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A53296Medicare UPIN