MEDICARE: GEORGIETTA R GDOVIN OD

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	OEG000359	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1518060482
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GEORGIETTA R GDOVIN OD

Provider Business Mailing Address
First Line	:	101 MONTGOMERY MALL
Second Line	:
City	:	NORTH WALES
State	:	PA
Zip	:	19454-3903
Country	:	US
Telephone Number	:	215-361-2400
Fax Number	:	215-361-0917

Provider Business Practice Location Address
First Line	:	101 MONTGOMERY MALL
Second Line	:
City	:	NORTH WALES
State	:	PA
Zip	:	19454
Country	:	US
Telephone Number	:	215-361-2400
Fax Number	:	215-361-0917

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

Provider Enumeration Date	:	09/06/2006
Last Update Date	:	08/22/2018

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Directions to “ GEORGIETTA R GDOVIN OD” Practice Location

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