Provider Demographics
NPI:1528155520
Name:MOLITORIS, ANTHONY T (OD)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:T
Last Name:MOLITORIS
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 1:1500 SANS SOUCI PKWY
Mailing Address - Street 2:
Mailing Address - City:HANOVER TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18706-6028
Mailing Address - Country:US
Mailing Address - Phone:570-823-0700
Mailing Address - Fax:570-823-6704
Practice Address - Street 1:1500 SANS SOUCI PKWY
Practice Address - Street 2:
Practice Address - City:HANOVER TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18706-6028
Practice Address - Country:US
Practice Address - Phone:570-823-0700
Practice Address - Fax:570-823-6704
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000470152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA061615OtherPTAN
PA0363510001Medicare UPIN