Provider Demographics
NPI:1568462125
Name:WYWIORSKI, BARBARA (OD)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:
Last Name:WYWIORSKI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:BARBARA
Other - Middle Name:M
Other - Last Name:YANAK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:16 MIX AVE
Mailing Address - Street 2:
Mailing Address - City:TOWANDA
Mailing Address - State:PA
Mailing Address - Zip Code:18848-1948
Mailing Address - Country:US
Mailing Address - Phone:570-265-8135
Mailing Address - Fax:570-268-8990
Practice Address - Street 1:16 MIX AVE
Practice Address - Street 2:
Practice Address - City:TOWANDA
Practice Address - State:PA
Practice Address - Zip Code:18848-1948
Practice Address - Country:US
Practice Address - Phone:570-265-8135
Practice Address - Fax:570-268-8990
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000523152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014887860003Medicaid
PAWY1511629OtherBLUE SHIELD
3289060OtherAETNA
PA10893OtherGEISINGER
PA816925OtherFIRST PRIORITY
PA0014887860003Medicaid
PA461861Medicare PIN
PAWY1511629OtherBLUE SHIELD
P00056445Medicare PIN