Provider Demographics
NPI:1053301861
Name:HERTNEKY, GEORGE WALTER (OD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:WALTER
Last Name:HERTNEKY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 CAMERON ST
Mailing Address - Street 2:
Mailing Address - City:BRUSH
Mailing Address - State:CO
Mailing Address - Zip Code:80723-2015
Mailing Address - Country:US
Mailing Address - Phone:970-842-5166
Mailing Address - Fax:970-842-5167
Practice Address - Street 1:212 CAMERON ST
Practice Address - Street 2:
Practice Address - City:BRUSH
Practice Address - State:CO
Practice Address - Zip Code:80723-2015
Practice Address - Country:US
Practice Address - Phone:970-842-5166
Practice Address - Fax:970-842-5167
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT1893152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO8018939Medicaid
COHE40983OtherANTHEM BLUE CROSS BLUE SH
COU66575Medicare UPIN
CO8018939Medicaid
CO410033866Medicare PIN