Active NPI
Charles Clark Ertl, PH.D.
- Psychologist
- San Diego, CA
National Provider Identifier
1356375729
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Psychologist
- License
- PSY15479
- Practice address
- 10981 San Diego Mission Rd
Suite 114
San Diego, CA 92108-2448 - Phone
- (619) 286-2687
- Fax
- (619) 286-2687
- NPI assigned
- Jul 10, 2006
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychologist | 103T00000X | PSY15479 | CA | Primary |
Addresses
Primary practice location
10981 San Diego Mission Rd
Suite 114
San Diego, CA 92108-2448
Mailing address
4852 Lila Dr
San Diego, CA 92115-1910
Phone (619) 286-2687
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PSY15479 | CA | MD | Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1152489600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1356375729",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4852 LILA DR",
"city": "SAN DIEGO",
"state": "CA",
"postal_code": "921151910",
"telephone_number": "619-286-2687",
"fax_number": "619-286-2687"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "10981 SAN DIEGO MISSION RD",
"address_2": "SUITE 114",
"city": "SAN DIEGO",
"state": "CA",
"postal_code": "921082448",
"telephone_number": "619-286-2687",
"fax_number": "619-286-2687"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ERTL",
"first_name": "CHARLES",
"middle_name": "CLARK",
"credential": "PH.D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-07-10",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "103T00000X",
"taxonomy_group": "",
"desc": "Psychologist",
"state": "CA",
"license": "PSY15479",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in San Diego, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.