Provider Demographics
NPI:1841248143
Name:EWERTZ, GREGORY JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:JAMES
Last Name:EWERTZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1908 DALTON RD
Mailing Address - Street 2:
Mailing Address - City:PALOS VERDES ESTATES
Mailing Address - State:CA
Mailing Address - Zip Code:90274-2656
Mailing Address - Country:US
Mailing Address - Phone:310-375-5680
Mailing Address - Fax:
Practice Address - Street 1:8361 W 3RD ST
Practice Address - Street 2:SUITE 240-E
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-4312
Practice Address - Country:US
Practice Address - Phone:310-854-3400
Practice Address - Fax:310-854-5732
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG38676174400000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA92015Medicare UPIN
CAW14051Medicare ID - Type UnspecifiedGROUP PROVIDER ID