Provider Demographics
NPI:1710035712
Name:WERNER, DAVID MICHAEL (OD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
Last Name:WERNER
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 1:200 INDIAN CREEK DR
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-7825
Mailing Address - Country:US
Mailing Address - Phone:570-239-0665
Mailing Address - Fax:
Practice Address - Street 1:362 ST. CLAIR HIGHWAY
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901
Practice Address - Country:US
Practice Address - Phone:570-621-2020
Practice Address - Fax:570-628-4933
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001492152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1025215740001Medicaid
PA081064Y3QMedicare PIN