Provider Demographics
NPI:1699833855
Name:PREMIERVISION LASER CENTER, INC.
Entity type:Organization
Organization Name:PREMIERVISION LASER CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CORDELIA
Authorized Official - Middle Name:NKOLIKA
Authorized Official - Last Name:UDDOH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-657-5044
Mailing Address - Street 1:PO BOX 539
Mailing Address - Street 2:
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090-0539
Mailing Address - Country:US
Mailing Address - Phone:215-657-5044
Mailing Address - Fax:215-657-5046
Practice Address - Street 1:3212 W CHELTENHAM AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19150-1003
Practice Address - Country:US
Practice Address - Phone:215-657-5044
Practice Address - Fax:215-657-5046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD069007L207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
187975OtherMEDICARE-PTAN
PA1012162880001Medicaid