Organization
DURRIYA S ESAA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LISA L WAGNER (OFFICE MANAGER)
(570) 322-9948
Entity
Organization
Contact information
Practice address
1201 GRAMPIAN BLVD, SUITE 2C, WILLIAMSPORT, PA 17701-1900
(570) 322-9948
(570) 322-6195
Mailing address
1201 GRAMPIAN BLVD, SUITE 2C, WILLIAMSPORT, PA 17701-1900
(570) 322-9948
(570) 322-6195
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
Primary
MD043700L
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
097365
BLUE SHIELD
PA
05
—
1007503440003
—
PA
Enumeration date
06/26/2007
Last updated
11/19/2009
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