Provider Demographics
NPI:1144291865
Name:PEMBERTON, BARTHOLOMEW C (OD)
Entity type:Individual
Prefix:DR
First Name:BARTHOLOMEW
Middle Name:C
Last Name:PEMBERTON
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 1:4730 E PIMA ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-3521
Mailing Address - Country:US
Mailing Address - Phone:520-795-3956
Mailing Address - Fax:520-318-3431
Practice Address - Street 1:4730 E PIMA ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-3521
Practice Address - Country:US
Practice Address - Phone:520-795-3956
Practice Address - Fax:520-318-3431
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ944152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ27239Medicare ID - Type Unspecified
AZ27237Medicare ID - Type UnspecifiedGROUP NUMBER