Provider Demographics
NPI:1477674992
Name:FOTIADIS, IRENE (OPTICIAN)
Entity Type:Individual
Prefix:MRS
First Name:IRENE
Middle Name:
Last Name:FOTIADIS
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10752 BUSTLETON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19116-3367
Mailing Address - Country:US
Mailing Address - Phone:215-698-7450
Mailing Address - Fax:215-698-7451
Practice Address - Street 1:10752 BUSTLETON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19116-3367
Practice Address - Country:US
Practice Address - Phone:215-698-7450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA274722379156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA5955150001Medicare NSC