Provider Demographics
NPI:1841287364
Name:BETSKO, HEATHER R (OD)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:R
Last Name:BETSKO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:745 W BASELINE RD STE 21
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-6023
Mailing Address - Country:US
Mailing Address - Phone:480-461-3937
Mailing Address - Fax:480-461-0331
Practice Address - Street 1:777 W SOUTHERN AVE
Practice Address - Street 2:SUITE 515
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-5008
Practice Address - Country:US
Practice Address - Phone:480-461-3937
Practice Address - Fax:480-461-0331
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-29
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1386152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZV02228Medicare UPIN
AZZ108827Medicare PIN