Healthcare Provider Details

I. General information

NPI: 1982600243
Provider Name (Legal Business Name): JEFFREY F DESIMONE OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 08/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 E MAITLAND LN
NEW CASTLE PA
16105-1248
US

IV. Provider business mailing address

2 E MAITLAND LN
NEW CASTLE PA
16105-1248
US

V. Phone/Fax

Practice location:
  • Phone: 724-658-4700
  • Fax:
Mailing address:
  • Phone: 724-658-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG001767
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: