MEDICARE: GARY L. ETTING O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152WV0400X	Vision Therapy Optometrist	OPT5519T	CA

General Provider Information

NPI Number	:	1912969619
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARY L. ETTING O.D.

Provider Business Mailing Address
First Line	:	6345 BALBOA BLVD
Second Line	:	BLDG III, SUITE 250
City	:	ENCINO
State	:	CA
Zip	:	91316-1519
Country	:	US
Telephone Number	:	818-344-3937
Fax Number	:	818-344-1229

Provider Business Practice Location Address
First Line	:	6345 BALBOA BLVD
Second Line	:	BLDG III, SUITE 250
City	:	ENCINO
State	:	CA
Zip	:	91316-1519
Country	:	US
Telephone Number	:	818-344-3937
Fax Number	:	818-344-1229

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/06/2006
Last Update Date	:	01/08/2008

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