MEDICARE: SIDNEY I & JERRY P DAVIDOFF PTR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OEG000157	PA

General Provider Information

NPI Number	:	1356313688
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SIDNEY I & JERRY P DAVIDOFF PTR

Provider Business Mailing Address
First Line	:	2805 W CHESTER PIKE
Second Line	:	PO BOX 188
City	:	BROOMALL
State	:	PA
Zip	:	19008-1827
Country	:	US
Telephone Number	:	610-356-3933
Fax Number	:	610-356-3324

Provider Business Practice Location Address
First Line	:	2805 W CHESTER PIKE
Second Line	:
City	:	BROOMALL
State	:	PA
Zip	:	19008-1827
Country	:	US
Telephone Number	:	610-356-3933
Fax Number	:	610-356-3324

Authorized Official
Title or Position	:	PARTNER
Name	:	DR. JERRY PHILIP DAVIDOFF
Credential	:	O.D.
Telephone Number	:	610-356-3933

Provider Enumeration Date	:	02/02/2006
Last Update Date	:	06/24/2011

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