Provider Demographics
NPI:1184602229
Name:STASKIEWICZ, THOMAS B (OD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:B
Last Name:STASKIEWICZ
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:PO BOX 1976
Mailing Address - Street 2:4 ROBINHOOD DR
Mailing Address - City:CRANBERRY TWP
Mailing Address - State:PA
Mailing Address - Zip Code:16066-0976
Mailing Address - Country:US
Mailing Address - Phone:724-776-3033
Mailing Address - Fax:
Practice Address - Street 1:4 ROBINHOOD DR
Practice Address - Street 2:
Practice Address - City:CRANBERRY TWP
Practice Address - State:PA
Practice Address - Zip Code:16066
Practice Address - Country:US
Practice Address - Phone:724-776-3033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000448152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1259872Medicaid
PA198704Medicare ID - Type Unspecified
PA1259872Medicaid