Healthcare Provider Details

I. General information

NPI: 1922090323
Provider Name (Legal Business Name): PAUL FRED IVES OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 03/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 N WATER ST
WEST NEWTON PA
15089-1500
US

IV. Provider business mailing address

145 N WATER ST
WEST NEWTON PA
15089-1500
US

V. Phone/Fax

Practice location:
  • Phone: 724-872-5621
  • Fax: 724-872-6660
Mailing address:
  • Phone: 724-872-5621
  • Fax: 724-872-6660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG001122
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: