Provider Demographics
NPI:1164523924
Name:NISSEN, SARAH BETH (OD)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:BETH
Last Name:NISSEN
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 1:243 HAVERFORD RD
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-3318
Mailing Address - Country:US
Mailing Address - Phone:610-930-6858
Mailing Address - Fax:610-356-3324
Practice Address - Street 1:2805 W CHESTER PIKE
Practice Address - Street 2:
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008-1827
Practice Address - Country:US
Practice Address - Phone:610-356-3933
Practice Address - Fax:610-356-3324
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001885152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist