Provider Demographics
NPI:1013117019
Name:MARY REED DACANAL, OD INC.
Entity Type:Organization
Organization Name:MARY REED DACANAL, OD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:REED
Authorized Official - Last Name:DACANAL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:814-965-3231
Mailing Address - Street 1:516 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSONBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15845-1240
Mailing Address - Country:US
Mailing Address - Phone:814-965-3231
Mailing Address - Fax:814-965-5483
Practice Address - Street 1:516 MARKET ST
Practice Address - Street 2:
Practice Address - City:JOHNSONBURG
Practice Address - State:PA
Practice Address - Zip Code:15845-1240
Practice Address - Country:US
Practice Address - Phone:814-965-3231
Practice Address - Fax:814-965-5483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000721152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA069767OtherMEDICARE ID-TYPE UNSPECIF
PA1012058380001Medicaid
PA069767OtherMEDICARE ID-TYPE UNSPECIF
PAU24031Medicare UPIN