Healthcare Provider Details

I. General information

NPI: 1659421303
Provider Name (Legal Business Name): IRA NATHAN ETTINGER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 AROY DR.
WASHINGTON MO
63090
US

IV. Provider business mailing address

1229 WISSMANN DR
BALLWIN MO
63011-4362
US

V. Phone/Fax

Practice location:
  • Phone: 636-390-3285
  • Fax:
Mailing address:
  • Phone: 636-227-3067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberT02543
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: