Provider Demographics
NPI:1699708727
Name:PITTLER, GERALD THOMAS (OD)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:THOMAS
Last Name:PITTLER
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 1:855 LAKEVILLE ST STE 102
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-7328
Mailing Address - Country:US
Mailing Address - Phone:707-763-1423
Mailing Address - Fax:707-981-4582
Practice Address - Street 1:855 LAKEVILLE ST STE 102
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-7328
Practice Address - Country:US
Practice Address - Phone:707-763-1423
Practice Address - Fax:707-981-4582
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6321152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1699708727OtherNPI
CA1699708727OtherNPI
CASD0063210Medicare PIN