Provider Demographics
NPI:1700934460
Name:BETMALECK, EDMOND (OD)
Entity Type:Individual
Prefix:DR
First Name:EDMOND
Middle Name:
Last Name:BETMALECK
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 1:24305 TOWN CENTER DR
Mailing Address - Street 2:SUITE 160
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-1307
Mailing Address - Country:US
Mailing Address - Phone:661-799-7464
Mailing Address - Fax:661-799-7583
Practice Address - Street 1:24305 TOWN CENTER DR
Practice Address - Street 2:SUITE 160
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-1307
Practice Address - Country:US
Practice Address - Phone:661-799-7464
Practice Address - Fax:661-799-7583
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10286152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U53204Medicare UPIN
OP10286Medicare ID - Type Unspecified