Provider Demographics
NPI:1831114412
Name:LEBANON OPHTHALMIC ASSOCIATES
Entity Type:Organization
Organization Name:LEBANON OPHTHALMIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPHTHALMOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:717-272-2161
Mailing Address - Street 1:770 NORMAN DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-7495
Mailing Address - Country:US
Mailing Address - Phone:717-272-2161
Mailing Address - Fax:717-270-0301
Practice Address - Street 1:770 NORMAN DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-7495
Practice Address - Country:US
Practice Address - Phone:717-272-2161
Practice Address - Fax:717-270-0301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOE008055T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012029400001Medicaid
PALE544036Medicare ID - Type UnspecifiedGROUP NUMBER