Provider Demographics
NPI:1619910239
Name:NEIDERER, THERESA BOLAND (OD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:BOLAND
Last Name:NEIDERER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 TOWNSHIP LINE RD
Mailing Address - Street 2:STE 101
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-1925
Mailing Address - Country:US
Mailing Address - Phone:610-430-2228
Mailing Address - Fax:610-644-5410
Practice Address - Street 1:623 SWEDESFORD CORPORATE CENTER
Practice Address - Street 2:
Practice Address - City:FRAZER
Practice Address - State:PA
Practice Address - Zip Code:19355
Practice Address - Country:US
Practice Address - Phone:610-644-9300
Practice Address - Fax:610-644-5410
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOE006787-T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAU28349Medicare UPIN
PANE446562Medicare ID - Type Unspecified