Provider Demographics
NPI:1881787836
Name:BERTRAM, LILLIAN H (OD)
Entity type:Individual
Prefix:MS
First Name:LILLIAN
Middle Name:H
Last Name:BERTRAM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MS
Other - First Name:LILLIAN
Other - Middle Name:H
Other - Last Name:JUE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:843 NEWPORT CENTER DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-6943
Mailing Address - Country:US
Mailing Address - Phone:949-718-2040
Mailing Address - Fax:
Practice Address - Street 1:843 NEWPORT CENTER DR
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-6943
Practice Address - Country:US
Practice Address - Phone:949-718-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAT10103152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWOP10103Medicare ID - Type Unspecified
CAU43718Medicare UPIN