Healthcare Provider Details

I. General information

NPI: 1780725994
Provider Name (Legal Business Name): MARC M PENSAK OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1743 N KEYSER AVE
SCRANTON PA
18508-1261
US

IV. Provider business mailing address

1743 N KEYSER AVE
SCRANTON PA
18508-1261
US

V. Phone/Fax

Practice location:
  • Phone: 570-961-1400
  • Fax: 570-961-0744
Mailing address:
  • Phone: 570-961-1400
  • Fax: 570-961-0744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOE006491P PA
License Number StatePA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: