Basic Information
| Provider Information | |||||||||
| NPI: | 1578536041 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERSONIUS | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HARNOIS | ||||||||
| OtherFirstName: | CHRISTINA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3921 W LINCOLN HWY | ||||||||
| Address2: | |||||||||
| City: | DOWNINGTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193355502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102699595 | ||||||||
| FaxNumber: | 6102699613 | ||||||||
| Practice Location | |||||||||
| Address1: | 3921 W LINCOLN HWY | ||||||||
| Address2: | |||||||||
| City: | DOWNINGTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193355502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102699595 | ||||||||
| FaxNumber: | 6102699613 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2006 | ||||||||
| LastUpdateDate: | 09/27/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OEG000707 | PA | Y | Eye and Vision Services Providers | Optometrist | 152W00000X | 4094 | MA | N | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 2927764 | 01 | PA | AETNA | OTHER | PA0707 | 01 | PA | EYE MED | OTHER | P00080142 | 01 | PA | RAILROAD MEDICARE | OTHER | PE 1313911 | 01 | PA | BC BS | OTHER | 217381 | 01 | COLE | OTHER |