1639751225 NPI number — OPTOMETRIC PHYSICIANS OF MIDDLETOWN PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639751225 NPI number — OPTOMETRIC PHYSICIANS OF MIDDLETOWN PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTOMETRIC PHYSICIANS OF MIDDLETOWN PA
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:
CLARKSON EYECARE
Provider Other Organization Name Type Code:
3
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:
1639751225
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 208944
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75320-8944
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-200-4393
Provider Business Mailing Address Fax Number:
636-527-0766

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 ROUTE 70 UNIT B1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANCHESTER
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08759-5804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-657-1400
Provider Business Practice Location Address Fax Number:
732-657-1402
Provider Enumeration Date:
04/23/2021

Additional Information

Authorized Official

Authorized Official Last Name:
WACHTER
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
636-200-4393

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)





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