Provider Demographics
NPI:1174107866
Name:KETCHUM, BERT EDMOND III (OD)
Entity type:Individual
Prefix:DR
First Name:BERT
Middle Name:EDMOND
Last Name:KETCHUM
Suffix:III
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:TREY
Other - Middle Name:
Other - Last Name:KETCHUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:USNH/USNMRTC GUANTANAMO BAY, CUBA
Mailing Address - Street 2:PSC 1005 BOX 110185
Mailing Address - City:FPO
Mailing Address - State:AA
Mailing Address - Zip Code:34009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:USNH/USNMRTC GUANTANAMO BAY, CUBA
Practice Address - Street 2:PSC 1005 BOX 110185
Practice Address - City:FPO
Practice Address - State:AA
Practice Address - Zip Code:34009
Practice Address - Country:US
Practice Address - Phone:757-458-2998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-08
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618003037152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist