Provider Demographics
NPI:1902013824
Name:PENN OPTICAL CO. LTD
Entity Type:Organization
Organization Name:PENN OPTICAL CO. LTD
Other - Org Name:PENN OPTICAL VISION CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:FUSS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:410-488-6800
Mailing Address - Street 1:5006 SINCLAIR LN
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21206-5936
Mailing Address - Country:US
Mailing Address - Phone:410-488-6800
Mailing Address - Fax:410-488-4270
Practice Address - Street 1:5006 SINCLAIR LN
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21206-5936
Practice Address - Country:US
Practice Address - Phone:410-488-6800
Practice Address - Fax:410-488-4270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD152W00000X, 152WC0802X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Single Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
No152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD792848300Medicaid
MD687720600Medicaid
MD754302600Medicaid
MD281428500Medicaid
MD050678800Medicaid
MD789538100Medicaid
MD050698200Medicaid
MD265668000Medicaid
MD265668000Medicaid
MD050678800Medicaid
MD0188500009Medicare NSC
MD281428500Medicaid
MD0188500008Medicare NSC
MD0188500007Medicare NSC
MD0188500004Medicare NSC
MD0188500001Medicare NSC