1417969528 NPI number — MARY A DESANDO OD

Table of content: MARY A DESANDO OD (NPI 1417969528)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417969528 NPI number — MARY A DESANDO OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DESANDO
Provider First Name:
MARY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

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:
1417969528
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 MIFFLIN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCRANTON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-342-3145
Provider Business Mailing Address Fax Number:
570-344-1309

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 BROOKLYN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARBONDALE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-282-7188
Provider Business Practice Location Address Fax Number:
570-282-4402
Provider Enumeration Date:
08/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OEG000527 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 506554 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 20969 . This is a "GEISINGER HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 001163415 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 073339 . This is a "FIRST PRIORITY HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: DE567588 . This is a "HIGH MARK BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 410024727 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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