Provider Demographics
NPI:1598850349
Name:AMOS, GWENN (OD)
Entity Type:Individual
Prefix:DR
First Name:GWENN
Middle Name:
Last Name:AMOS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:43 HENDRICKS ST
Mailing Address - Street 2:
Mailing Address - City:AMBLER
Mailing Address - State:PA
Mailing Address - Zip Code:19002-4433
Mailing Address - Country:US
Mailing Address - Phone:215-654-9718
Mailing Address - Fax:215-276-1329
Practice Address - Street 1:1200 W GODFREY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3323
Practice Address - Country:US
Practice Address - Phone:215-276-6000
Practice Address - Fax:215-276-1329
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001350152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0321825000OtherKHPE
PA00091343OtherRAILROAD MEDICARE
PA2248OtherAETNA HMO
PA1762595OtherBLUE SHIELD
PA2248OtherAETNA HMO
PA00091343OtherRAILROAD MEDICARE