Provider Demographics
NPI:1538158860
Name:DEITZ-BERTKE, CAROL (OD)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:DEITZ-BERTKE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:LYNN
Other - Last Name:DEITZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:2486 LEGENDS WAY
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW HILLS
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3479
Mailing Address - Country:US
Mailing Address - Phone:859-341-0888
Mailing Address - Fax:859-341-3386
Practice Address - Street 1:581 DUDLEY PIKE
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3296
Practice Address - Country:US
Practice Address - Phone:859-341-0888
Practice Address - Fax:859-341-3386
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1134DT152W00000X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000049502OtherBLUE CROSS &BLUE SHIELD
KY9296901Medicare ID - Type Unspecified
KY0845260001Medicare NSC
KYT92078Medicare UPIN