Healthcare Provider Details

I. General information

NPI: 1376056978
Provider Name (Legal Business Name): MAZY EYE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2017
Last Update Date: 11/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 MONUMENT RD
PHILADELPHIA PA
19131-1600
US

IV. Provider business mailing address

1705 CLYDESDALE CIR
YARDLEY PA
19067-4114
US

V. Phone/Fax

Practice location:
  • Phone: 215-220-4455
  • Fax:
Mailing address:
  • Phone: 609-638-0102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG003001
License Number StatePA

VIII. Authorized Official

Name: DR. QURTULLEAN MALIK
Title or Position: OPTOMETRIST
Credential: OD
Phone: 609-638-0102