Healthcare Provider Details

I. General information

NPI: 1033410014
Provider Name (Legal Business Name): GERALD T PITTLER O. D. INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2010
Last Update Date: 01/12/2023
Certification Date: 12/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 LAKEVILLE ST SUITE 102
PETALUMA CA
94952-7327
US

IV. Provider business mailing address

855 LAKEVILLE ST SUITE 102
PETALUMA CA
94952-7327
US

V. Phone/Fax

Practice location:
  • Phone: 707-763-1423
  • Fax: 707-981-4582
Mailing address:
  • Phone: 707-763-1423
  • Fax: 707-981-4582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number6321
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number6321
License Number StateCA

VIII. Authorized Official

Name: GERALD T PITTLER
Title or Position: PRESIDENT
Credential: OD
Phone: 707-763-1423