Provider Demographics
NPI:1740328418
Name:MALKOUN, ISSAM (OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:ISSAM
Middle Name:
Last Name:MALKOUN
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:427 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-3215
Mailing Address - Country:US
Mailing Address - Phone:610-566-9272
Mailing Address - Fax:
Practice Address - Street 1:3103 CHICHESTER AVE
Practice Address - Street 2:
Practice Address - City:BOOTHWYN
Practice Address - State:PA
Practice Address - Zip Code:19061-3117
Practice Address - Country:US
Practice Address - Phone:610-494-4320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA23273485156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
0134700001OtherNSC
0134700001OtherNSC