Provider Demographics
NPI:1336706571
Name:YERGER, ETHAN MICHAEL (RD)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:MICHAEL
Last Name:YERGER
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1681 CHOPTANK RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-9043
Mailing Address - Country:US
Mailing Address - Phone:302-893-9845
Mailing Address - Fax:
Practice Address - Street 1:200 E VINE ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-5531
Practice Address - Country:US
Practice Address - Phone:443-358-6445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-23
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX4709133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered