Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 152WC0802X | Optometrist | Corneal and Contact Management | OPC 4250 | FLORIDA | No |
| 2 | 152WP0200X | Optometrist | Pediatrics | OPC 4250 | FLORIDA | No |
| 3 | 152WS0006X | Optometrist | Sports Vision | OPC 4250 | FLORIDA | No |
| 4 | 152W00000X | Optometrist | | OEG-000812 | PENNSYLVANIA | No |
| 5 | 152W00000X | Optometrist | | 5350/T2259 | OHIO | No |
| 6 | 152WC0802X | Optometrist | Corneal and Contact Management | OEG-000812 | PENNSYLVANIA | No |
| 7 | 152WC0802X | Optometrist | Corneal and Contact Management | 5350/T2259 | OHIO | No |
| 8 | 152WP0200X | Optometrist | Pediatrics | OEG-000812 | PENNSYLVANIA | No |
| 9 | 152WP0200X | Optometrist | Pediatrics | 5350/T2259 | OHIO | No |
| 10 | 152WS0006X | Optometrist | Sports Vision | OEG-000812 | PENNSYLVANIA | No |
| 11 | 152WS0006X | Optometrist | Sports Vision | 5350/T2259 | OHIO | No |
| 12 | 152WX0102X | Optometrist | Occupational Vision | OEG-000812 | PENNSYLVANIA | No |
| 13 | 152WX0102X | Optometrist | Occupational Vision | 5350/T2259 | OHIO | No |
| 14 | 152W00000X | Optometrist | | OPC 4250 | FLORIDA | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 50054 | OTHER | PENNSYLVANIA | DAVIS VISION ID |
| 2 | U91193 | MEDICARE UPIN | PENNSYLVANIA | |
| 3 | 220961 | OTHER | PENNSYLVANIA | COLE MANAGED VISON ID |
| 4 | 101463734 0002 | MEDICAID | PENNSYLVANIA | |
| 5 | 241675 | OTHER | PENNSYLVANIA | HLTH AM/ASSR/ADVANTRA ID |
| 6 | 397597 | OTHER | PENNSYLVANIA | NATIONAL VISION ADMIN. ID |
| 7 | 313229 | OTHER | PENNSYLVANIA | UPMC HEALTH PLAN ID |
| 8 | 3002066 | OTHER | PENNSYLVANIA | AETNA PROVIDER ID |
| 9 | 220961 | OTHER | PENNSYLVANIA | EYEMED ID |
| 10 | WY1395963 | OTHER | PENNSYLVANIA | BLUE CRSS/SHLD PROV ID |
| 11 | 410049273 | MEDICARE ID-TYPE UNSPECIFIED | PENNSYLVANIA | RAILROAD MEDICARE ID |
| 12 | 1646983 | OTHER | PENNSYLVANIA | HIGHMARK GROUP ID |
| 13 | 083790 | MEDICARE ID-TYPE UNSPECIFIED | PENNSYLVANIA | MEDICARE 1 MAN GROUP ID |
| 14 | 059972S74 | MEDICARE ID-TYPE UNSPECIFIED | PENNSYLVANIA | MEDICARE PROVIDER ID |
