Provider Demographics
NPI:1801874367
Name:BURRELL, JOHN J (OD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:BURRELL
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 1:10 CLEARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:TROOPER
Mailing Address - State:PA
Mailing Address - Zip Code:19403-1655
Mailing Address - Country:US
Mailing Address - Phone:610-631-1142
Mailing Address - Fax:
Practice Address - Street 1:10 CLEARFIELD AVE
Practice Address - Street 2:
Practice Address - City:TROOPER
Practice Address - State:PA
Practice Address - Zip Code:19403-1655
Practice Address - Country:US
Practice Address - Phone:610-631-1142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000682152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001453726Medicaid
189495RHGMedicare ID - Type Unspecified
PA001453726Medicaid