Healthcare Provider Details

I. General information

NPI: 1669497889
Provider Name (Legal Business Name): DR. MERVIN W STOLTZFUS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 03/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 NEWPORT AVE
CHRISTIANA PA
17509-1312
US

IV. Provider business mailing address

PO BOX 75
CHRISTIANA PA
17509-0075
US

V. Phone/Fax

Practice location:
  • Phone: 610-593-6670
  • Fax:
Mailing address:
  • Phone: 610-593-6670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG001396
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: