Provider Demographics
NPI:1295187805
Name:TANNEN, NOAH (OD)
Entity Type:Individual
Prefix:
First Name:NOAH
Middle Name:
Last Name:TANNEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W GODFREY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141-3323
Mailing Address - Country:US
Mailing Address - Phone:215-276-6173
Mailing Address - Fax:215-276-1329
Practice Address - Street 1:1200 W GODFREY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3323
Practice Address - Country:US
Practice Address - Phone:215-276-6173
Practice Address - Fax:215-276-1329
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003179152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA13854036OtherCAQH NUMBER