=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215044680
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LOUIS MICHAEL BERTRAM OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2006
-----------------------------------------------------
Last Update Date | 10/01/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 185 COMMERCIAL DR
-----------------------------------------------------
City | VANCEBURG
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41179-6181
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-796-3295
-----------------------------------------------------
Fax | 606-796-9285
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 185 COMMERCIAL DR
-----------------------------------------------------
City | VANCEBURG
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41179-6181
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-796-3295
-----------------------------------------------------
Fax | 606-796-9285
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1060DT
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------