Provider Demographics
NPI:1407996119
Name:KATZ, MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:KATZ
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 1:3225 COLONIAL RD
Mailing Address - Street 2:
Mailing Address - City:HATBORO
Mailing Address - State:PA
Mailing Address - Zip Code:19040-1633
Mailing Address - Country:US
Mailing Address - Phone:631-512-2063
Mailing Address - Fax:
Practice Address - Street 1:3225 COLONIAL RD
Practice Address - Street 2:
Practice Address - City:HATBORO
Practice Address - State:PA
Practice Address - Zip Code:19040-1633
Practice Address - Country:US
Practice Address - Phone:631-512-2063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYT004297152W00000X
PAOEG002574152W00000X, 152WX0102X, 152WV0400X, 152WS0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA236789OtherMEDICARE PTAN