Provider Demographics
NPI:1497144083
Name:MODERN OPTOMETRY, INC.
Entity Type:Organization
Organization Name:MODERN OPTOMETRY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:VERNA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:610-662-4855
Mailing Address - Street 1:3300 GRANT AVE STE 21
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114-2632
Mailing Address - Country:US
Mailing Address - Phone:215-335-9090
Mailing Address - Fax:215-333-5225
Practice Address - Street 1:3300 GRANT AVE STE 21
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-2632
Practice Address - Country:US
Practice Address - Phone:215-335-9090
Practice Address - Fax:215-333-5225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-20
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000070152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA058136Medicare PIN