Provider Demographics
NPI:1164465795
Name:JOSEFOWICZ, MICHAEL RICHARD JR (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RICHARD
Last Name:JOSEFOWICZ
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:703 RUTTER AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-4801
Mailing Address - Country:US
Mailing Address - Phone:570-288-7406
Mailing Address - Fax:570-288-7406
Practice Address - Street 1:703 RUTTER AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-4801
Practice Address - Country:US
Practice Address - Phone:410-571-8733
Practice Address - Fax:570-288-7406
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000229152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA9866OtherDAVIS VISION
PA397325OtherNVA
PAJO896903OtherBLUE CROSS
PA938921OtherEYEMED