Provider Demographics
NPI:1467658476
Name:DURRIYA S ESAA
Entity Type:Organization
Organization Name:DURRIYA S ESAA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-322-9948
Mailing Address - Street 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1900
Mailing Address - Country:US
Mailing Address - Phone:570-322-9948
Mailing Address - Fax:570-322-6195
Practice Address - Street 1:1201 GRAMPIAN BLVD
Practice Address - Street 2:SUITE 2C
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-1900
Practice Address - Country:US
Practice Address - Phone:570-322-9948
Practice Address - Fax:570-322-6195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD043700L207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007503440003Medicaid
PA097365OtherBLUE SHIELD
PA097365OtherBLUE SHIELD
PA1297130001Medicare NSC
PA090617Medicare PIN