Provider Demographics
NPI:1417969528
Name:DESANDO, MARY A (OD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:DESANDO
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 1:200 MIFFLIN AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18503
Mailing Address - Country:US
Mailing Address - Phone:570-342-3145
Mailing Address - Fax:570-344-1309
Practice Address - Street 1:150 BROOKLYN ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:PA
Practice Address - Zip Code:18407
Practice Address - Country:US
Practice Address - Phone:570-282-7188
Practice Address - Fax:570-282-4402
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000527152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
506554OtherAETNA
20969OtherGEISINGER HEALTH PLAN
PA001163415Medicaid
073339OtherFIRST PRIORITY HEALTH
DE567588OtherHIGH MARK BLUE SHIELD
410024727OtherRAILROAD MEDICARE
20969OtherGEISINGER HEALTH PLAN
PA567588Medicare ID - Type Unspecified