Provider Demographics
NPI:1760490494
Name:BROOKHAVEN FAMILY EYE CARE CENTER
Entity Type:Organization
Organization Name:BROOKHAVEN FAMILY EYE CARE CENTER
Other - Org Name:BROOKHAVEN VISION SOURCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:DE JESSE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:610-872-8989
Mailing Address - Street 1:4106 EDGMONT AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:19015-2314
Mailing Address - Country:US
Mailing Address - Phone:610-872-8989
Mailing Address - Fax:610-872-5220
Practice Address - Street 1:4106 EDGMONT AVE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:PA
Practice Address - Zip Code:19015-2314
Practice Address - Country:US
Practice Address - Phone:610-872-8989
Practice Address - Fax:610-872-5220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001547152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2115330000OtherINDEPENDENCE BLUE CROSS
PACM9120OtherRAILROAD MEDICARE
PA001429488OtherHIGHMARK
PA5498366OtherAETNA UNIVERSAL GROUP
PA2628516OtherAETNA GROUP HMO
PACM9120OtherRAILROAD MEDICARE
PA525125Medicare PIN