Provider Demographics
NPI:1679730071
Name:ROBERT OTTAVIANI OD
Entity type:Organization
Organization Name:ROBERT OTTAVIANI OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSEMARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:OTTAVIANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-746-1610
Mailing Address - Street 1:P.O. BOX 307
Mailing Address - Street 2:
Mailing Address - City:WYALUSING
Mailing Address - State:PA
Mailing Address - Zip Code:18853-0307
Mailing Address - Country:US
Mailing Address - Phone:570-746-1610
Mailing Address - Fax:570-746-6218
Practice Address - Street 1:55 MAIN ST
Practice Address - Street 2:
Practice Address - City:WYALUSING
Practice Address - State:PA
Practice Address - Zip Code:18853-0307
Practice Address - Country:US
Practice Address - Phone:570-746-1610
Practice Address - Fax:570-746-6218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000822152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty