Provider Demographics
NPI:1245348465
Name:ETCHELLS, PHILIP TANNER (OD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:TANNER
Last Name:ETCHELLS
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 1:13692 APPLE VALLEY RD
Mailing Address - Street 2:# 170
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92308
Mailing Address - Country:US
Mailing Address - Phone:760-961-1919
Mailing Address - Fax:760-961-1907
Practice Address - Street 1:13692 APPLE VALLEY RD
Practice Address - Street 2:# 170
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92308
Practice Address - Country:US
Practice Address - Phone:760-961-1919
Practice Address - Fax:760-961-1907
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5518T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD005181Medicaid
CA5292930001Medicare NSC
SD0055180Medicare ID - Type Unspecified
CASD005181Medicaid
CAGQ888AMedicare PIN