Provider Demographics
NPI:1538337902
Name:TRI COUNTY EYE CLINIC, PLLC
Entity type:Organization
Organization Name:TRI COUNTY EYE CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPHTHALMOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:EMILE
Authorized Official - Last Name:BERTUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-385-2020
Mailing Address - Street 1:15122 DEDEAUX RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3120
Mailing Address - Country:US
Mailing Address - Phone:228-832-1242
Mailing Address - Fax:228-832-1285
Practice Address - Street 1:15122 DEDEAUX RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3120
Practice Address - Country:US
Practice Address - Phone:228-832-1242
Practice Address - Fax:228-832-1285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2019-03-29
Deactivation Date:2018-05-14
Deactivation Code:
Reactivation Date:2019-03-29
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty