Provider Demographics
NPI:1760973101
Name:ROSENTHAL, BETHANY T (OD)
Entity Type:Individual
Prefix:DR
First Name:BETHANY
Middle Name:T
Last Name:ROSENTHAL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-454-6026
Mailing Address - Fax:314-454-2368
Practice Address - Street 1:1 CHILDRENS PL
Practice Address - Street 2:STE 3110
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1002
Practice Address - Country:US
Practice Address - Phone:314-454-6026
Practice Address - Fax:314-454-2368
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018014542152WP0200X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO310054310Medicaid