Provider Demographics
NPI:1093770570
Name:BERTRAM, PAUL TIMOTHY (OD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:TIMOTHY
Last Name:BERTRAM
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 1:705 BUTTERMILK PIKE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CRESCENT SPRINGS
Mailing Address - State:KY
Mailing Address - Zip Code:41017-1303
Mailing Address - Country:US
Mailing Address - Phone:859-341-3937
Mailing Address - Fax:
Practice Address - Street 1:705 BUTTERMILK PIKE
Practice Address - Street 2:SUITE 100
Practice Address - City:CRESCENT SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:41017-1303
Practice Address - Country:US
Practice Address - Phone:859-341-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1569DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77000974Medicaid