Healthcare Provider Details

I. General information

NPI: 1760973101
Provider Name (Legal Business Name): BETHANY T ROSENTHAL OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2018
Last Update Date: 04/17/2025
Certification Date: 05/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL STE 3110
SAINT LOUIS MO
63110-1002
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-6026
  • Fax: 866-936-4559
Mailing address:
  • Phone: 314-454-6026
  • Fax: 866-936-4559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number2018014542
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2018014542
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: