Provider Demographics
NPI:1659421303
Name:ETTINGER, IRA NATHAN (OD)
Entity Type:Individual
Prefix:DR
First Name:IRA
Middle Name:NATHAN
Last Name:ETTINGER
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 1:1229 WISSMANN DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-4362
Mailing Address - Country:US
Mailing Address - Phone:636-227-3067
Mailing Address - Fax:
Practice Address - Street 1:1701 AROY DR.
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090
Practice Address - Country:US
Practice Address - Phone:636-390-3285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02543152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management