Basic Information
| Provider Information | |||||||||
| NPI: | 1477724581 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DELAWARE VALLEY VISION ASSOCIATES GROUP PRACTICE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 MALL BLVD | ||||||||
| Address2: | |||||||||
| City: | KING OF PRUSSIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194062902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103371580 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 MALL BLVD | ||||||||
| Address2: | |||||||||
| City: | KING OF PRUSSIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194062902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103371580 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2008 | ||||||||
| LastUpdateDate: | 03/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6104912127 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1745652 | 01 | PA | BLUE SHIELD | OTHER |