Provider Demographics
NPI:1629700240
Name:ZWOLAN, BENJAMIN NIKOLAI (OD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:NIKOLAI
Last Name:ZWOLAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 VARSITY LN
Mailing Address - Street 2:
Mailing Address - City:BEAR
Mailing Address - State:DE
Mailing Address - Zip Code:19701-3904
Mailing Address - Country:US
Mailing Address - Phone:570-573-6313
Mailing Address - Fax:
Practice Address - Street 1:1601 KIRKWOOD HWY
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805-4917
Practice Address - Country:US
Practice Address - Phone:302-994-2511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-30
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003900152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist