MEDICARE: DR. GARY JON KOKOSKY O.D.

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	OEG-000213	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MA887976	OTHER	PA	BLUE SHIELD
2	50023492	OTHER	PA	CAPITAL BC

General Provider Information

NPI Number	:	1518003789
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY JON KOKOSKY O.D.

Provider Business Mailing Address
First Line	:	3220 GLASE RD
Second Line	:
City	:	DANIELSVILLE
State	:	PA
Zip	:	18038-9692
Country	:	US
Telephone Number	:	610-837-2394
Fax Number	:

Provider Business Practice Location Address
First Line	:	147 PALMER PARK MALL
Second Line	:
City	:	EASTON
State	:	PA
Zip	:	18045-2759
Country	:	US
Telephone Number	:	610-258-4372
Fax Number	:	610-258-5878

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	01/03/2008

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