Healthcare Provider Details

I. General information

NPI: 1013483387
Provider Name (Legal Business Name): MARY HUANG DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2018
Last Update Date: 10/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 LEOPARD RD
PAOLI PA
19301-1518
US

IV. Provider business mailing address

31 LEOPARD RD
PAOLI PA
19301-1518
US

V. Phone/Fax

Practice location:
  • Phone: 484-595-0345
  • Fax:
Mailing address:
  • Phone: 484-595-0345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG001597
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: