Healthcare Provider Details

I. General information

NPI: 1588629984
Provider Name (Legal Business Name): DONNA LEONNE ELCOCK O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 02/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

538 CHURCH LN
YEADON PA
19050-3102
US

IV. Provider business mailing address

538 CHURCH LN
YEADON PA
19050-3102
US

V. Phone/Fax

Practice location:
  • Phone: 610-284-0777
  • Fax:
Mailing address:
  • Phone: 610-284-0777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOEG001054
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier73236
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerAETNA
# 2
Identifier0530914000
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerKEYSTONE HEALTH PLAN EAST
# 3
Identifier01622622
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 4
Identifier695858
Identifier TypeOTHER
Identifier StatePW
Identifier IssuerPERSONAL CHOICE/ BLUE CHO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: