Provider Demographics
NPI:1881733509
Name:UNVERDORBEN, EDWARD A (ABOC)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:A
Last Name:UNVERDORBEN
Suffix:
Gender:M
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:268 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15202-2938
Mailing Address - Country:US
Mailing Address - Phone:412-849-4564
Mailing Address - Fax:
Practice Address - Street 1:268 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15202-2938
Practice Address - Country:US
Practice Address - Phone:412-849-4564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA01005156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1152250001Medicare ID - Type Unspecified