Provider Demographics
NPI:1043296965
Name:HARVEY, BERTRAM TARLETON IV (OD)
Entity Type:Individual
Prefix:DR
First Name:BERTRAM
Middle Name:TARLETON
Last Name:HARVEY
Suffix:IV
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:TARRY
Other - Middle Name:BERTRAM
Other - Last Name:HARVEY
Other - Suffix:IV
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:2001 46TH AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-3250
Mailing Address - Country:US
Mailing Address - Phone:970-330-7070
Mailing Address - Fax:970-330-8382
Practice Address - Street 1:2001 46TH AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-3250
Practice Address - Country:US
Practice Address - Phone:970-330-7070
Practice Address - Fax:970-330-8382
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1962152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U71538Medicare UPIN
CO0331790002Medicare NSC
COCF0133Medicare PIN