Basic Information
| Provider Information | |||||||||
| NPI: | 1043864283 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CIOCOTISAN | ||||||||
| FirstName: | IOAN | ||||||||
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| Credential: | OPTOMETRIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 MARK LN | ||||||||
| Address2: | |||||||||
| City: | EWING | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 086281509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6097516280 | ||||||||
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| Practice Location | |||||||||
| Address1: | 550 E LANCASTER AVE STE C1 | ||||||||
| Address2: | |||||||||
| City: | RADNOR | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190875044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106870364 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2019 | ||||||||
| LastUpdateDate: | 07/29/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OEG003565 | PA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.