Provider Demographics
NPI:1720020019
Name:MERVIN W STOLTZFUS OD
Entity Type:Organization
Organization Name:MERVIN W STOLTZFUS OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MERVIN
Authorized Official - Middle Name:W
Authorized Official - Last Name:STOLTZFUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-593-6670
Mailing Address - Street 1:PO BOX 75
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANA
Mailing Address - State:PA
Mailing Address - Zip Code:17509
Mailing Address - Country:US
Mailing Address - Phone:610-593-6670
Mailing Address - Fax:
Practice Address - Street 1:316 NEWPORT AVE
Practice Address - Street 2:
Practice Address - City:CHRISTIANA
Practice Address - State:PA
Practice Address - Zip Code:17509-1312
Practice Address - Country:US
Practice Address - Phone:610-593-6670
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001396152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0546535Medicaid
T27207Medicare UPIN
0518120001Medicare NSC
PA0546535Medicaid