Provider Demographics
NPI:1215044680
Name:BERTRAM, LOUIS MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:LOUIS
Middle Name:MICHAEL
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 1:185 COMMERCIAL DR
Mailing Address - Street 2:
Mailing Address - City:VANCEBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41179-6181
Mailing Address - Country:US
Mailing Address - Phone:606-796-3295
Mailing Address - Fax:606-796-9285
Practice Address - Street 1:185 COMMERCIAL DR
Practice Address - Street 2:
Practice Address - City:VANCEBURG
Practice Address - State:KY
Practice Address - Zip Code:41179-6181
Practice Address - Country:US
Practice Address - Phone:606-796-3295
Practice Address - Fax:606-796-9285
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1060DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77010601Medicaid
KY9223001Medicare ID - Type Unspecified
KY77010601Medicaid