Healthcare Provider Details

I. General information

NPI: 1639125214
Provider Name (Legal Business Name): BEN DOMIANO OPTICAL INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

817 S MAIN ST
OLD FORGE PA
18518-1431
US

IV. Provider business mailing address

817 S MAIN ST
OLD FORGE PA
18518-1431
US

V. Phone/Fax

Practice location:
  • Phone: 570-457-2020
  • Fax: 570-457-2787
Mailing address:
  • Phone: 570-457-2020
  • Fax: 570-457-2787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierPA817
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerVISION BENEFITS OF AMERIC
# 2
Identifier48926
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerGEISINGER
# 3
Identifier15932
Identifier TypeOTHER
Identifier StateMD
Identifier IssuerSPECTARA
# 4
Identifier9911
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerDAVIS VISION
# 5
IdentifierDO0001565000
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerHIGHMARK
# 6
IdentifierBE282600
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerCLARITY VISION
# 7
IdentifierPA0685
Identifier TypeOTHER
Identifier StateOH
Identifier IssuerEYEMED/COLE VISION
# 8
Identifier393342
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerNVA

VIII. Authorized Official

Name: BENJAMIN G DOMIANO
Title or Position: PRESIDENT
Credential: ABOC OPTICIAN
Phone: 570-457-2020