Provider Demographics
NPI:1124179833
Name:HAIDLER, BERNARD JAMES (OD)
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:JAMES
Last Name:HAIDLER
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 1:17 CORONET AVE
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-1164
Mailing Address - Country:US
Mailing Address - Phone:415-388-6505
Mailing Address - Fax:
Practice Address - Street 1:53 COLMA BLVD
Practice Address - Street 2:STE F2 280 METRO CENTER
Practice Address - City:COLMA
Practice Address - State:CA
Practice Address - Zip Code:94014-3231
Practice Address - Country:US
Practice Address - Phone:650-992-2700
Practice Address - Fax:650-992-3215
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT5863152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU32200Medicare UPIN