Healthcare Provider Details

I. General information

NPI: 1548273600
Provider Name (Legal Business Name): LISA M MONGIELLO OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 12/01/2022
Certification Date: 12/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MIFFLIN AVE
SCRANTON PA
18503
US

IV. Provider business mailing address

200 MIFFLIN AVE
SCRANTON PA
18503
US

V. Phone/Fax

Practice location:
  • Phone: 570-342-3145
  • Fax: 570-344-1309
Mailing address:
  • Phone: 570-342-3145
  • Fax: 570-344-1309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG000231
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier15788
Identifier TypeOTHER
Identifier State
Identifier IssuerGEISINGER HEALTH PLAN
# 2
Identifier001504280
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 3
Identifier506554
Identifier TypeOTHER
Identifier State
Identifier IssuerAETNA
# 4
IdentifierM0774785
Identifier TypeOTHER
Identifier State
Identifier IssuerHIGHMARK BLUE SHIELD
# 5
Identifier410032103
Identifier TypeOTHER
Identifier State
Identifier IssuerRAILROAD MEDICARE
# 6
Identifier081377
Identifier TypeOTHER
Identifier State
Identifier IssuerFIRST PRIORITY HEALTH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: