Healthcare Provider Details

I. General information

NPI: 1043216898
Provider Name (Legal Business Name): MARK MARGOLIES OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 06/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 STONYBROOK DR
LEVITTOWN PA
19055-2216
US

IV. Provider business mailing address

1724 KENDRICK ST
PHILADELPHIA PA
19152-1816
US

V. Phone/Fax

Practice location:
  • Phone: 215-946-1221
  • Fax: 215-946-1225
Mailing address:
  • Phone: 215-946-1221
  • Fax: 215-946-1225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG000972
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOEG000972
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: