Provider Demographics
NPI:1578887931
Name:LEONARD D. GERVINSKI, O.D.
Entity Type:Organization
Organization Name:LEONARD D. GERVINSKI, O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:DENNIS
Authorized Official - Last Name:GERVINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:724-335-7331
Mailing Address - Street 1:96 CRAIGDELL ROAD
Mailing Address - Street 2:
Mailing Address - City:LOWER BURRELL
Mailing Address - State:PA
Mailing Address - Zip Code:15068-2987
Mailing Address - Country:US
Mailing Address - Phone:724-335-7331
Mailing Address - Fax:724-335-1390
Practice Address - Street 1:96 CRAIGDELL ROAD
Practice Address - Street 2:
Practice Address - City:LOWER BURRELL
Practice Address - State:PA
Practice Address - Zip Code:15068-2987
Practice Address - Country:US
Practice Address - Phone:724-335-7331
Practice Address - Fax:724-335-1390
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEONARD D. GERVINSKI, O.D.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-03-15
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOE-005204T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000546670Medicaid
PAGE25400Medicare UPIN
PAT-27134Medicare PIN