Provider Demographics
NPI:1659413292
Name:MCCOY, BERT (OD)
Entity Type:Individual
Prefix:
First Name:BERT
Middle Name:
Last Name:MCCOY
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 1:11640 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-1923
Mailing Address - Country:US
Mailing Address - Phone:909-627-7363
Mailing Address - Fax:909-627-9854
Practice Address - Street 1:11640 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-1923
Practice Address - Country:US
Practice Address - Phone:909-627-7363
Practice Address - Fax:909-627-9854
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT4766TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0047660Medicare PIN