Provider Demographics
NPI:1558468017
Name:DUSZAK, ROBERT S (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:S
Last Name:DUSZAK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2112 PINE ST
Mailing Address - Street 2:APT 2
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-2573
Mailing Address - Country:US
Mailing Address - Phone:215-520-2329
Mailing Address - Fax:
Practice Address - Street 1:3900 WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4551
Practice Address - Country:US
Practice Address - Phone:215-823-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000317152W00000X
DEI3-0001278152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U92602Medicare UPIN
064377Medicare ID - Type Unspecified