Provider Demographics
NPI:1386746436
Name:ETTINGER, HENRY (OD)
Entity type:Individual
Prefix:
First Name:HENRY
Middle Name:
Last Name:ETTINGER
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 1:42044 VILLAGE 42
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-8902
Mailing Address - Country:US
Mailing Address - Phone:646-648-2459
Mailing Address - Fax:
Practice Address - Street 1:2705 TELLER RD
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91320-1190
Practice Address - Country:US
Practice Address - Phone:805-262-0038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7866152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYT65132Medicare UPIN
C33741Medicare ID - Type Unspecified