MEDICARE: MARY TERESE DACANAL 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	OEG000721	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	:	1528054285
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY TERESE DACANAL O.D.

Provider Business Mailing Address
First Line	:	516 MARKET ST
Second Line	:
City	:	JOHNSONBURG
State	:	PA
Zip	:	15845-1240
Country	:	US
Telephone Number	:	816-965-3231
Fax Number	:

Provider Business Practice Location Address
First Line	:	516 MARKET ST
Second Line	:
City	:	JOHNSONBURG
State	:	PA
Zip	:	15845-1240
Country	:	US
Telephone Number	:	814-965-3231
Fax Number	:

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

Provider Enumeration Date	:	09/27/2005
Last Update Date	:	10/22/2012

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