Provider Demographics
NPI:1528039559
Name:BERTRAM, LINDA R (OD)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:R
Last Name:BERTRAM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E KINCAID ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-428-2500
Mailing Address - Fax:360-428-6485
Practice Address - Street 1:1990 HOSPITAL DRIVE
Practice Address - Street 2:SUITE 110
Practice Address - City:SEDRO WOOLLEY
Practice Address - State:WA
Practice Address - Zip Code:98284
Practice Address - Country:US
Practice Address - Phone:360-854-2750
Practice Address - Fax:360-854-2755
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003471152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA263647OtherLABOR & INDUSTRIES
WA1528039559Medicaid
WA1528039559Medicaid
CAT 107688Medicare UPIN