Basic Information
| Provider Information | |||||||||
| NPI: | 1760973101 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSENTHAL | ||||||||
| FirstName: | BETHANY | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 S EUCLID AVE | ||||||||
| Address2: | CB 8096 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144546026 | ||||||||
| FaxNumber: | 3144542368 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 CHILDRENS PL | ||||||||
| Address2: | STE 3110 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144546026 | ||||||||
| FaxNumber: | 3144542368 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2018 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WP0200X | 2018014542 | MO | N | Eye and Vision Services Providers | Optometrist | Pediatrics | 152W00000X | 2018014542 | MO | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 310054310 | 05 | MO | MEDICAID |