Provider Demographics
NPI:1760587588
Name:KETOVER, BART (MD)
Entity Type:Individual
Prefix:
First Name:BART
Middle Name:
Last Name:KETOVER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72057 DINAH SHORE DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-1791
Mailing Address - Country:US
Mailing Address - Phone:760-340-3937
Mailing Address - Fax:760-340-1941
Practice Address - Street 1:72057 DINAH SHORE DR
Practice Address - Street 2:SUITE D
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-1791
Practice Address - Country:US
Practice Address - Phone:760-340-3937
Practice Address - Fax:760-340-1941
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG 84707207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D60098Medicare UPIN
00G847070Medicare PIN