1740392448 NPI number — DR. FORREST KEITH UMBEL O.D.

Table of content: DR. FORREST KEITH UMBEL O.D. (NPI 1740392448)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740392448 NPI number — DR. FORREST KEITH UMBEL O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
UMBEL
Provider First Name:
FORREST
Provider Middle Name:
KEITH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
UMBEL
Provider Other First Name:
F
Provider Other Middle Name:
KEITH
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
O.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1740392448
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
60 SUE ANNE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15701-3652
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-357-9929
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3100 OAKLAND AVE
Provider Second Line Business Practice Location Address:
C/O WALMART VISION CENTER
Provider Business Practice Location Address City Name:
INDIANA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15701-3240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-349-5671
Provider Business Practice Location Address Fax Number:
724-340-6375
Provider Enumeration Date:
08/31/2006

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:  OEG001086 , 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: 001740107001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".