Healthcare Provider Details

I. General information

NPI: 1679693741
Provider Name (Legal Business Name): ELISA BANO OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5001 FRANKFORD AVE
PHILADELPHIA PA
19124-2619
US

IV. Provider business mailing address

5001 FRANKFORD AVE
PHILADELPHIA PA
19124-2619
US

V. Phone/Fax

Practice location:
  • Phone: 215-288-5000
  • Fax: 215-744-1233
Mailing address:
  • Phone: 215-288-5000
  • Fax: 215-744-1233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG002681
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number5793
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number27OA00851100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: