Provider Demographics
NPI:1265737159
Name:JON L MARBERGER
Entity type:Organization
Organization Name:JON L MARBERGER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:L
Authorized Official - Last Name:MARBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:215-576-1321
Mailing Address - Street 1:PO BOX 429
Mailing Address - Street 2:
Mailing Address - City:GLENSIDE
Mailing Address - State:PA
Mailing Address - Zip Code:19038-0429
Mailing Address - Country:US
Mailing Address - Phone:215-576-1321
Mailing Address - Fax:215-886-6892
Practice Address - Street 1:2256 MOUNT CARMEL AVE
Practice Address - Street 2:
Practice Address - City:GLENSIDE
Practice Address - State:PA
Practice Address - Zip Code:19038-4610
Practice Address - Country:US
Practice Address - Phone:215-576-1321
Practice Address - Fax:215-886-6892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-24
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000871152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0850850001Medicare NSC
PAT27592Medicare UPIN