Provider Demographics
NPI:1265632152
Name:VAN HARTESVELT, DAVID (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:VAN HARTESVELT
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12902 FOOTHILL BLVD
Mailing Address - Street 2:SUITE H
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-4900
Mailing Address - Country:US
Mailing Address - Phone:818-837-3818
Mailing Address - Fax:818-837-3820
Practice Address - Street 1:12902 FOOTHILL BLVD
Practice Address - Street 2:SUITE H
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-4900
Practice Address - Country:US
Practice Address - Phone:818-837-3818
Practice Address - Fax:818-837-3820
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACL1190156FC0801X
CASL4082156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens Fitter