Provider Demographics
NPI:1639275696
Name:SIRACUSE, CARLENE ANN (OPTOMETRIST)
Entity Type:Individual
Prefix:MRS
First Name:CARLENE
Middle Name:ANN
Last Name:SIRACUSE
Suffix:
Gender:F
Credentials:OPTOMETRIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MIFFLIN AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18503-1982
Mailing Address - Country:US
Mailing Address - Phone:570-342-3145
Mailing Address - Fax:570-344-1309
Practice Address - Street 1:1850 S TOWNSHIP BLVD
Practice Address - Street 2:STE 6
Practice Address - City:PITTSTON
Practice Address - State:PA
Practice Address - Zip Code:18640
Practice Address - Country:US
Practice Address - Phone:570-651-1641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001828152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1017833590001Medicaid
PA108157G2MMedicare ID - Type Unspecified
PA1017833590001Medicaid