Healthcare Provider Details

I. General information

NPI: 1477565224
Provider Name (Legal Business Name): JAMIE A ELLSWORTH-NEIMAN OPTOMETRIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 W GODFREY AVE
PHILADELPHIA PA
19141-3323
US

IV. Provider business mailing address

50 FIELDSTONE RD
LEVITTOWN PA
19056-1917
US

V. Phone/Fax

Practice location:
  • Phone: 215-276-6000
  • Fax: 215-276-1329
Mailing address:
  • Phone: 215-945-2625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberOEG000343
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: