Provider Demographics
NPI:1689867764
Name:PERSIC, LOUIS ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:LOUIS
Middle Name:ANTHONY
Last Name:PERSIC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 HUNTER AVE
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-6947
Mailing Address - Country:US
Mailing Address - Phone:814-237-1450
Mailing Address - Fax:814-234-2686
Practice Address - Street 1:222 HUNTER AVE
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-6947
Practice Address - Country:US
Practice Address - Phone:814-237-1450
Practice Address - Fax:814-234-2686
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-22
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD012700E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAC28271Medicare UPIN