Provider Demographics
NPI:1043819352
Name:ELTERMAN, DOUGLAS GREGORY
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:GREGORY
Last Name:ELTERMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2180 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-4558
Mailing Address - Country:US
Mailing Address - Phone:805-781-4275
Mailing Address - Fax:805-781-1277
Practice Address - Street 1:2180 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4558
Practice Address - Country:US
Practice Address - Phone:805-788-2524
Practice Address - Fax:805-788-2056
Is Sole Proprietor?:No
Enumeration Date:2020-10-19
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1363730919171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator