Provider Demographics
NPI:1659695344
Name:DR. BERTOLLI OD & ASSOCIATES LLC
Entity Type:Organization
Organization Name:DR. BERTOLLI OD & ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:BERTOLLI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:203-238-3080
Mailing Address - Street 1:470 LEWIS AVENUE
Mailing Address - Street 2:C/O SEARS OPTICAL
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06451
Mailing Address - Country:US
Mailing Address - Phone:203-238-3080
Mailing Address - Fax:203-238-0207
Practice Address - Street 1:470 LEWIS AVENUE
Practice Address - Street 2:C/O SEARS OPTICAL
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06451
Practice Address - Country:US
Practice Address - Phone:203-238-3080
Practice Address - Fax:203-238-0207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-24
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2015152W00000X
152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty