Provider Demographics
NPI:1356375729
Name:ERTL, CHARLES CLARK (PHD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:CLARK
Last Name:ERTL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4852 LILA DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-1910
Mailing Address - Country:US
Mailing Address - Phone:619-286-2687
Mailing Address - Fax:619-286-2687
Practice Address - Street 1:10981 SAN DIEGO MISSION RD
Practice Address - Street 2:SUITE 114
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-2448
Practice Address - Country:US
Practice Address - Phone:619-286-2687
Practice Address - Fax:619-286-2687
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15479103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP15479Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER