Healthcare Provider Details

I. General information

NPI: 1679793749
Provider Name (Legal Business Name): BRUCE S KIRSHNER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 WILKES BORRE TWP BLVD SAMS CLUB OPTICAL
WILKES BARRE PA
18702
US

IV. Provider business mailing address

21 N DAWES AVE
KINGSTON PA
18704
US

V. Phone/Fax

Practice location:
  • Phone: 570-821-5513
  • Fax: 570-821-5514
Mailing address:
  • Phone: 570-762-3582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOE005125T
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: