Provider Demographics
NPI:1053507236
Name:PENN OPTICAL CO. LTD
Entity Type:Organization
Organization Name:PENN OPTICAL CO. LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:FUSS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:410-327-7070
Mailing Address - Street 1:5006 SINCLAIR LN
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21206-5936
Mailing Address - Country:US
Mailing Address - Phone:410-488-6800
Mailing Address - Fax:410-488-4270
Practice Address - Street 1:2122 E MONUMENT ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21205-2334
Practice Address - Country:US
Practice Address - Phone:410-327-7070
Practice Address - Fax:410-327-7072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Single Specialty
No152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0188500006Medicare NSC