Provider Demographics
NPI:1770579880
Name:LAFAYETTE EYE ASSOCIATES, P.C.
Entity type:Organization
Organization Name:LAFAYETTE EYE ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:N
Authorized Official - Last Name:ITZENSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:610-825-3937
Mailing Address - Street 1:413 GERMANTOWN PIKE
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19444-1816
Mailing Address - Country:US
Mailing Address - Phone:610-825-3937
Mailing Address - Fax:610-825-0381
Practice Address - Street 1:413 GERMANTOWN PIKE
Practice Address - Street 2:
Practice Address - City:LAFAYETTE HILL
Practice Address - State:PA
Practice Address - Zip Code:19444-1816
Practice Address - Country:US
Practice Address - Phone:610-825-3937
Practice Address - Fax:610-825-0381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-23
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOE006115T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA6369300001Medicare NSC
PA778275Medicare PIN