Provider Demographics
NPI:1104802404
Name:ZEITLIN, IRA CHARLES (OD)
Entity type:Individual
Prefix:
First Name:IRA
Middle Name:CHARLES
Last Name:ZEITLIN
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 1:3935 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-3181
Mailing Address - Country:US
Mailing Address - Phone:215-386-6200
Mailing Address - Fax:
Practice Address - Street 1:3935 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-3110
Practice Address - Country:US
Practice Address - Phone:215-386-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOE005729T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0145640501Medicaid
PAT72483Medicare UPIN
PA0447200001Medicare NSC
PA050272Medicare PIN