Provider Demographics
NPI:1164415303
Name:MALLEUS, KAREN W (OD)
Entity Type:Individual
Prefix:DR
First Name:KAREN
Middle Name:W
Last Name:MALLEUS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LITITZ
Mailing Address - State:PA
Mailing Address - Zip Code:17543-1941
Mailing Address - Country:US
Mailing Address - Phone:717-626-8100
Mailing Address - Fax:717-626-0389
Practice Address - Street 1:65 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LITITZ
Practice Address - State:PA
Practice Address - Zip Code:17543-1941
Practice Address - Country:US
Practice Address - Phone:717-626-8100
Practice Address - Fax:717-626-0389
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001056152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA454462FGXMedicare ID - Type Unspecified
PA0300830001Medicare NSC
PA109027Medicare ID - Type UnspecifiedGROUP #
PAT30522Medicare UPIN