Provider Demographics
NPI:1578532826
Name:SPONBERG, MICHAEL J (O,D)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:SPONBERG
Suffix:
Gender:M
Credentials:O,D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8118 BUSTLETON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-2803
Mailing Address - Country:US
Mailing Address - Phone:215-342-8118
Mailing Address - Fax:215-725-4999
Practice Address - Street 1:8118 BUSTLETON AVE
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19152-2803
Practice Address - Country:US
Practice Address - Phone:215-342-8118
Practice Address - Fax:215-725-4999
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOE005574T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T27644Medicare UPIN