| National Provider Identifier [NPI]: | 1629096631 |
| Last Name Of The Provider | ETTTARI |
| First Name Of The Provider | CHARLES |
| Middle Initial Of The Provider | V |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 9834 GENESEE AVE |
| Street Address 2 Of The Provider | SUITE 427 |
| City Of The Provider | LA JOLLA |
| Zip Code Of The Provider | 920371264 |
| State Code Of The Provider | CA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Psychiatry |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 10 |
| Number Of Services | 154 |
| Number Of Medicare Beneficiaries | 101 |
| Total Submitted Charge Amount | 42400.92 |
| Total Medicare Allowed Amount | 16701.7 |
| Total Medicare Payment Amount | 13094.31 |
| Total Medicare Standardized Payment Amount | 12841.35 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 0 |
| Number Of Drug Services | 0 |
| Number Of Medicare Beneficiaries With Drug Services | 0 |
| Total Drug Submitted ChargeAmount | 0 |
| Total Drug Medicare AllowedAmount | 0 |
| Total Drug Medicare PaymentAmount | 0 |
| Total Drug Medicare Standardized Payment Amount | 0 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 10 |
| Number Of Medical Services | 154 |
| Number Of Medicare Beneficiaries With Medical Services | 101 |
| Total Medical Submitted Charge Amount | 42400.92 |
| Total Medical Medicare Allowed Amount | 16701.7 |
| Total Medical Medicare Payment Amount | 13094.31 |
| Total Medical Medicare Standardized Payment Amount | 12841.35 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 23 |
| Number Of Beneficiaries Age 65 to 74 | 31 |
| Number Of Beneficiaries Age 75 to 84 | 25 |
| Number Of Beneficiaries Age Greater 84 | 22 |
| Number Of Female Beneficiaries | 53 |
| Number Of Male Beneficiaries | 48 |
| Number Of Non Hispanic White Beneficiaries | 85 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 70 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 31 |
| Percent Of With Atrial Fibrillation | 31 |
| Percent Of With Alzheimers Disease or Dementia | 48 |
| Percent Of With Asthma | 12 |
| Percent Of With Cancer | 12 |
| Percent Of With Heart Failure | 49 |
| Percent Of With Chronic Kidney Disease | 46 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 30 |
| Percent Of With Depression | 68 |
| Percent Of With Diabetes | 31 |
| Percent Of With Hyperlipidemia | 57 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 48 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 49 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 36 |
| Percent Of With Stroke | 18 |
| Average HCC Risk Score Of Beneficiaries | 1.9606 |