MEDICARE: OM OPTICAL

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

General Provider Information

NPI Number	:	1639644172
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OM OPTICAL

Provider Business Mailing Address
First Line	:	3617 SIPLER LN
Second Line	:
City	:	HUNTINGDON VALLEY
State	:	PA
Zip	:	19006-3223
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1318 WALNUT ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-5410
Country	:	US
Telephone Number	:	215-370-5431
Fax Number	:

Authorized Official
Title or Position	:	PRES
Name	:	MARK MILLER
Credential	:
Telephone Number	:	215-370-5431

Provider Enumeration Date	:	10/11/2018
Last Update Date	:	10/11/2018

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Directions to “OM OPTICAL ” Practice Location

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