Healthcare Provider Details

I. General information

NPI: 1275182842
Provider Name (Legal Business Name): ANTONINA KORNEEVA OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2019
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 CHESTNUT ST LBBY 105
PHILADELPHIA PA
19103-3456
US

IV. Provider business mailing address

1919 CHESTNUT ST LBBY 105
PHILADELPHIA PA
19103-3456
US

V. Phone/Fax

Practice location:
  • Phone: 215-563-8440
  • Fax: 215-567-4993
Mailing address:
  • Phone: 215-563-8440
  • Fax: 215-567-4993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG003762
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: