Healthcare Provider Details

I. General information

NPI: 1235129941
Provider Name (Legal Business Name): JOHN D OPALKA O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 02/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 N MCKEAN ST
KITTANNING PA
16201-1565
US

IV. Provider business mailing address

131 N MCKEAN ST
KITTANNING PA
16201-1565
US

V. Phone/Fax

Practice location:
  • Phone: 724-543-2702
  • Fax: 724-543-5171
Mailing address:
  • Phone: 724-543-2702
  • Fax: 724-543-5171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG000706
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: