Basic Information
| Provider Information | |||||||||
| NPI: | 1417911678 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERTRAM | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | DANIELS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 705 BUTTERMILK PIKE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CRESCENT SPRINGS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410171303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593413937 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 705 BUTTERMILK PIKE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CRESCENT SPRINGS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410171303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593413937 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 07/22/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1570DT | KY | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 77001030 | 05 | KY | MEDICAID |