Healthcare Provider Details

I. General information

NPI: 1891782215
Provider Name (Legal Business Name): RICHARD EUGENE MARGERUM OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 09/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

326 N MAIN ST
MOSCOW PA
18444-9155
US

IV. Provider business mailing address

326 N MAIN ST PO BOX 747
MOSCOW PA
18444-9155
US

V. Phone/Fax

Practice location:
  • Phone: 570-842-2400
  • Fax:
Mailing address:
  • Phone: 570-842-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG000593
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: