Healthcare Provider Details

I. General information

NPI: 1093770570
Provider Name (Legal Business Name): PAUL TIMOTHY BERTRAM O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 02/24/2026
Certification Date: 02/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

989 GOVERNORS LN
LEXINGTON KY
40513-1173
US

IV. Provider business mailing address

989 GOVERNORS LN
LEXINGTON KY
40513-1173
US

V. Phone/Fax

Practice location:
  • Phone: 859-554-8265
  • Fax: 859-277-4490
Mailing address:
  • Phone: 859-554-8265
  • Fax: 859-277-4490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1569DT
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: