Provider Demographics
NPI:1790843977
Name:CUTHBERTSON, JILL DIANE (OD)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:DIANE
Last Name:CUTHBERTSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1344 W 38TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16508-2462
Mailing Address - Country:US
Mailing Address - Phone:814-868-0895
Mailing Address - Fax:814-868-0896
Practice Address - Street 1:1344 W 38TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16508-2462
Practice Address - Country:US
Practice Address - Phone:814-868-0895
Practice Address - Fax:814-868-0896
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001531152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA44402OtherDAVIS
PA396826OtherNVA
PA0019618410001Medicaid
PA396826OtherNVA
PA44402OtherDAVIS