Provider Demographics
NPI:1144248766
Name:BETTELHEIM, ERIC A (OD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:A
Last Name:BETTELHEIM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 W ARROW HWY
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-5411
Mailing Address - Country:US
Mailing Address - Phone:626-914-2414
Mailing Address - Fax:626-332-0094
Practice Address - Street 1:601 W ARROW HWY
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-5411
Practice Address - Country:US
Practice Address - Phone:626-914-2414
Practice Address - Fax:626-335-2635
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8672 TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0086720Medicaid
CASD0086720Medicaid
CADS5852Medicare PIN