Healthcare Provider Details

I. General information

NPI: 1174107866
Provider Name (Legal Business Name): BERT EDMOND KETCHUM III OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: TREY KETCHUM

II. Dates (important events)

Enumeration Date: 05/08/2021
Last Update Date: 06/06/2024
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USNH/USNMRTC GUANTANAMO BAY, CUBA PSC 1005 BOX 110185
FPO AA
34009
US

IV. Provider business mailing address

USNH/USNMRTC GUANTANAMO BAY, CUBA PSC 1005 BOX 110185
FPO AA
34009
US

V. Phone/Fax

Practice location:
  • Phone: 757-458-2998
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618003037
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: