Provider Demographics
NPI:1881862696
Name:FREDERIC A. NEISTADT O.D.
Entity Type:Organization
Organization Name:FREDERIC A. NEISTADT O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:VELAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:NRCMA
Authorized Official - Phone:610-437-0717
Mailing Address - Street 1:2200 W HAMILTON ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-6337
Mailing Address - Country:US
Mailing Address - Phone:610-437-0717
Mailing Address - Fax:610-437-3741
Practice Address - Street 1:2200 W HAMILTON ST
Practice Address - Street 2:SUITE 300
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-6337
Practice Address - Country:US
Practice Address - Phone:610-437-0717
Practice Address - Fax:610-437-3741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000893152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0178500001Medicare NSC