Provider Demographics
NPI:1912970112
Name:MUCKER, MICHAEL PAUL (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:PAUL
Last Name:MUCKER
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 1:1513 SCALP AVE
Mailing Address - Street 2:SUITE 280
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15904-3331
Mailing Address - Country:US
Mailing Address - Phone:814-266-7611
Mailing Address - Fax:814-266-3532
Practice Address - Street 1:1513 SCALP AVE
Practice Address - Street 2:SUITE 280
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15904-3331
Practice Address - Country:US
Practice Address - Phone:814-266-7611
Practice Address - Fax:814-266-3532
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG 001077152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014035000001Medicaid
PAT27026Medicare UPIN
PA3964Medicare ID - Type Unspecified