Provider Demographics
NPI:1598976581
Name:BOUQUET MULLIGAN DEMAIO EYE PROFESSIONALS
Entity Type:Organization
Organization Name:BOUQUET MULLIGAN DEMAIO EYE PROFESSIONALS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMININSTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRACALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-272-0581
Mailing Address - Street 1:1676 S MARKET ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17022-2853
Mailing Address - Country:US
Mailing Address - Phone:717-272-0581
Mailing Address - Fax:
Practice Address - Street 1:1676 S MARKET ST
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:PA
Practice Address - Zip Code:17022-2853
Practice Address - Country:US
Practice Address - Phone:717-272-0581
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA959599Medicare ID - Type UnspecifiedMEDICARE ID