=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275182842
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANTONINA KORNEEVA OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2019
-----------------------------------------------------
Last Update Date | 01/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1919 CHESTNUT ST LBBY 105
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19103-3456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-563-8440
-----------------------------------------------------
Fax | 215-567-4993
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1919 CHESTNUT ST LBBY 105
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19103-3456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-563-8440
-----------------------------------------------------
Fax | 215-567-4993
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OEG003762
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------