Provider Demographics
NPI:1558381913
Name:LOSE, JEFFREY R (OD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:R
Last Name:LOSE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:JEFFREY
Other - Middle Name:R
Other - Last Name:LOSE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:41 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17837-1944
Mailing Address - Country:US
Mailing Address - Phone:570-524-4489
Mailing Address - Fax:570-524-2817
Practice Address - Street 1:41 S 3RD ST
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:PA
Practice Address - Zip Code:17837-1944
Practice Address - Country:US
Practice Address - Phone:570-524-4489
Practice Address - Fax:570-524-2817
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOE006132T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA438071YPKMedicare PIN
PAT30439Medicare UPIN