Active NPI
Philip Tanner Etchells, OD
- Optometrist
- Apple Valley, CA
National Provider Identifier
1245348465
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Optometrist
- License
- 5518T
- Practice address
- 13692 Apple Valley Rd
# 170
Apple Valley, CA 92308 - Phone
- (760) 961-1919
- Fax
- (760) 961-1907
- NPI assigned
- Aug 28, 2006
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist | 152W00000X | 5518T | CA | Primary |
Addresses
Primary practice location
13692 Apple Valley Rd
# 170
Apple Valley, CA 92308
Mailing address
13692 Apple Valley Rd
# 170
Apple Valley, CA 92308
Phone (760) 961-1919
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| SD005181 | Medicaid | CA |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 5518T | CA | MD | Optometrist |
| 5518 | CA | MD | Physical Therapy Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1156723200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1367452800000",
"number": "1245348465",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "13692 APPLE VALLEY RD",
"address_2": "# 170",
"city": "APPLE VALLEY",
"state": "CA",
"postal_code": "92308",
"telephone_number": "760-961-1919",
"fax_number": "760-961-1907"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "13692 APPLE VALLEY RD",
"address_2": "# 170",
"city": "APPLE VALLEY",
"state": "CA",
"postal_code": "92308",
"telephone_number": "760-961-1919",
"fax_number": "760-961-1907"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ETCHELLS",
"first_name": "PHILIP",
"middle_name": "TANNER",
"credential": "OD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-08-28",
"last_updated": "2013-05-02",
"status": "A"
},
"taxonomies": [
{
"code": "152W00000X",
"taxonomy_group": "",
"desc": "Optometrist",
"state": "CA",
"license": "5518T",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "SD005181",
"state": "CA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Apple Valley, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 2, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.