=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104366053
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY MORITZ O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2017
-----------------------------------------------------
Last Update Date | 08/13/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4002 CHESTNUT ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-921-4871
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 37 BONNYWICK DR
-----------------------------------------------------
City | HARRISBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17111-4933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-319-0778
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | I3-0001391
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OEG003227
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------