Provider Demographics
NPI:1902058126
Name:L. MICHAEL BERTRAM OD PLLC
Entity Type:Organization
Organization Name:L. MICHAEL BERTRAM OD PLLC
Other - Org Name:DR. L. MICHAEL BERTRAM OD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:BERTRAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:606-796-3295
Mailing Address - Street 1:185 COMMERCIAL DR
Mailing Address - Street 2:
Mailing Address - City:VANCEBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41179-6181
Mailing Address - Country:US
Mailing Address - Phone:606-796-3295
Mailing Address - Fax:606-796-9285
Practice Address - Street 1:185 COMMERCIAL DR
Practice Address - Street 2:
Practice Address - City:VANCEBURG
Practice Address - State:KY
Practice Address - Zip Code:41179-6181
Practice Address - Country:US
Practice Address - Phone:606-796-3295
Practice Address - Fax:606-796-9285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1060DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77010601Medicaid
KYT54117Medicare UPIN
KY9530Medicare PIN