Healthcare Provider Details

I. General information

NPI: 1184305013
Provider Name (Legal Business Name): ETIENNE BINGHAM OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2023
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 S COBB ST STE 101
PALMER AK
99645-6480
US

IV. Provider business mailing address

9795 E TRENNIE LOOP UNIT 2
PALMER AK
99645-9160
US

V. Phone/Fax

Practice location:
  • Phone: 907-745-2273
  • Fax: 907-745-2312
Mailing address:
  • Phone: 907-707-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number246532
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: