=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033410014
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GERALD T PITTLER O. D. INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2010
-----------------------------------------------------
Last Update Date | 01/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 855 LAKEVILLE ST SUITE 102
-----------------------------------------------------
City | PETALUMA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94952-7327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-763-1423
-----------------------------------------------------
Fax | 707-981-4582
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 855 LAKEVILLE ST SUITE 102
-----------------------------------------------------
City | PETALUMA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94952-7327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-763-1423
-----------------------------------------------------
Fax | 707-981-4582
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | GERALD T PITTLER
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 707-763-1423
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 6321
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 6321
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------