1063523108 NPI number — BARBARA ANN GORDEUK OD LLC

Table of content: (NPI 1063523108)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063523108 NPI number — BARBARA ANN GORDEUK OD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BARBARA ANN GORDEUK OD LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063523108
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4899 DURHAM RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PIPERSVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18947-1151
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-766-3997
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
495 S OXFORD VALLEY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRLESS HILLS
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19030-4202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-949-6611
Provider Business Practice Location Address Fax Number:
215-949-6613
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GORDEUK
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
215-968-0203

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PA6881 . This is a "EYEMED" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 36092 . This is a "DAVIS VISION-WALMART" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 53028 . This is a "DAVIS VISION-KEYSTONE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0192730000 . This is a "INDEPENDENCE BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 57599 . This is a "AETNA-US HEALTHCARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 01851714 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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