Provider Demographics
NPI:1659604478
Name:TIMOTHY R. CORL OD, PC
Entity Type:Organization
Organization Name:TIMOTHY R. CORL OD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:CORL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:717-269-5346
Mailing Address - Street 1:100 N LONDONDERRY SQ
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:PA
Mailing Address - Zip Code:17078-3904
Mailing Address - Country:US
Mailing Address - Phone:717-838-9484
Mailing Address - Fax:717-838-9582
Practice Address - Street 1:100 N LONDONDERRY SQ
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:PA
Practice Address - Zip Code:17078-3904
Practice Address - Country:US
Practice Address - Phone:717-838-9484
Practice Address - Fax:717-838-9582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-11
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001986152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1022848630001Medicaid
PA147438Medicare PIN