Provider Demographics
NPI:1568416766
Name:BERTRAM LOVE, NICOLE EMILY (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:EMILY
Last Name:BERTRAM LOVE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14770 TRIADELPHIA MILL RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:MD
Mailing Address - Zip Code:21036-1215
Mailing Address - Country:US
Mailing Address - Phone:410-913-3740
Mailing Address - Fax:301-596-9271
Practice Address - Street 1:8415 BELLONA LN
Practice Address - Street 2:SUITE 212
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-2055
Practice Address - Country:US
Practice Address - Phone:410-913-3740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0044675207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD0044675OtherSTATE MEDICAL LICENSE
MDE98140Medicare UPIN