Provider Demographics
NPI:1427112069
Name:FAILLACE, KAREN M (OD)
Entity type:Individual
Prefix:DR
First Name:KAREN
Middle Name:M
Last Name:FAILLACE
Suffix:
Gender:F
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:RT 29 AND RT 3023
Mailing Address - Street 2:BOX 163
Mailing Address - City:DIMOCK
Mailing Address - State:PA
Mailing Address - Zip Code:18816-0163
Mailing Address - Country:US
Mailing Address - Phone:570-278-2882
Mailing Address - Fax:570-278-2422
Practice Address - Street 1:RT 29 AND RT 3023
Practice Address - Street 2:
Practice Address - City:DIMOCK
Practice Address - State:PA
Practice Address - Zip Code:18816-0163
Practice Address - Country:US
Practice Address - Phone:570-278-2882
Practice Address - Fax:570-278-2422
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001623152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA42881OtherDAVIS VISION
PAPA7153OtherEYEMED
PA622816OtherBLUECROSS
PA5702782882OtherVSP
PA83301OtherGEISINGER
PA0019241400002Medicaid
PA0019241400002Medicaid