Provider Demographics
NPI:1851383996
Name:JEFFERSON MEDICAL OPTICAL
Entity Type:Organization
Organization Name:JEFFERSON MEDICAL OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:TANNING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:412-466-6800
Mailing Address - Street 1:575 COAL VALLEY RD
Mailing Address - Street 2:SUITE 461
Mailing Address - City:JEFFERSON HILLS
Mailing Address - State:PA
Mailing Address - Zip Code:15025-3730
Mailing Address - Country:US
Mailing Address - Phone:412-466-6800
Mailing Address - Fax:412-466-8534
Practice Address - Street 1:575 COAL VALLEY RD
Practice Address - Street 2:SUITE 461
Practice Address - City:JEFFERSON HILLS
Practice Address - State:PA
Practice Address - Zip Code:15025-3730
Practice Address - Country:US
Practice Address - Phone:412-466-6800
Practice Address - Fax:412-466-8534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
069409H02Medicare ID - Type Unspecified
B34862Medicare UPIN