Healthcare Provider Details

I. General information

NPI: 1336148410
Provider Name (Legal Business Name): JACQUELINE R CARRASCO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 07/28/2020
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E LANCASTER AVE STE 54
WYNNEWOOD PA
19096-3438
US

IV. Provider business mailing address

100 E LANCASTER AVE STE 54
WYNNEWOOD PA
19096-3438
US

V. Phone/Fax

Practice location:
  • Phone: 610-649-1970
  • Fax:
Mailing address:
  • Phone: 610-649-1970
  • Fax: 610-649-8624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD416985
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number25MA07455900
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License NumberMD416985
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: