Provider Demographics
NPI:1477565224
Name:ELLSWORTH-NEIMAN, JAMIE A (OPTOMETRIST)
Entity Type:Individual
Prefix:DR
First Name:JAMIE
Middle Name:A
Last Name:ELLSWORTH-NEIMAN
Suffix:
Gender:M
Credentials:OPTOMETRIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 FIELDSTONE RD
Mailing Address - Street 2:
Mailing Address - City:LEVITTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19056-1917
Mailing Address - Country:US
Mailing Address - Phone:215-945-2625
Mailing Address - Fax:
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:215-276-6000
Practice Address - Fax:215-276-1329
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000343152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2248OtherAETNA HMO
PA2308338000OtherKEYSTONE EAST
PA1632843OtherBLUE SHIELD
PA2308338000OtherKEYSTONE EAST
PA052395Medicare ID - Type Unspecified