Provider Demographics
NPI:1902829518
Name:MAIZEL, MICHAEL B (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:B
Last Name:MAIZEL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 E BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:LANSDOWNE
Mailing Address - State:PA
Mailing Address - Zip Code:19050-2202
Mailing Address - Country:US
Mailing Address - Phone:610-623-1127
Mailing Address - Fax:484-461-8618
Practice Address - Street 1:20 E BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:LANSDOWNE
Practice Address - State:PA
Practice Address - Zip Code:19050-2202
Practice Address - Country:US
Practice Address - Phone:610-623-1127
Practice Address - Fax:484-461-8618
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000100152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T30080Medicare UPIN
PA194603S23Medicare PIN