Provider Demographics
NPI:1306950829
Name:GARY L ETTING OD AN OPTOMETRIC CORP
Entity type:Organization
Organization Name:GARY L ETTING OD AN OPTOMETRIC CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:ETTING
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:818-344-3937
Mailing Address - Street 1:6345 BALBOA BLVD
Mailing Address - Street 2:BLDG 3 SUITE 250
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316
Mailing Address - Country:US
Mailing Address - Phone:818-344-3937
Mailing Address - Fax:818-344-1229
Practice Address - Street 1:6345 BALBOA BLVD
Practice Address - Street 2:BLDG 3 SUITE 250
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316
Practice Address - Country:US
Practice Address - Phone:818-344-3937
Practice Address - Fax:818-344-1229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 5519 T152WV0400X, 152W00000X
CAOPT5519152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWOP5519AOtherOTHER MEDICARE PTAN
CAWOP5519AOtherOTHER MEDICARE PTAN
CACB220386Medicare PIN
CAWY3364Medicare PIN