Provider Demographics
NPI:1871551556
Name:GERVINSKI, LEONARD D (OD)
Entity type:Individual
Prefix:
First Name:LEONARD
Middle Name:D
Last Name:GERVINSKI
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 1:96 CRAIGDELL ROAD
Mailing Address - Street 2:
Mailing Address - City:LOWER BURRELL
Mailing Address - State:PA
Mailing Address - Zip Code:15068-3026
Mailing Address - Country:US
Mailing Address - Phone:724-335-7331
Mailing Address - Fax:724-335-1390
Practice Address - Street 1:96 CRAIGDELL ROAD
Practice Address - Street 2:
Practice Address - City:LOWER BURRELL
Practice Address - State:PA
Practice Address - Zip Code:15068-3026
Practice Address - Country:US
Practice Address - Phone:724-335-7331
Practice Address - Fax:724-335-1390
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0E005204T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00546670Medicaid
T27134Medicare UPIN
GE25400Medicare ID - Type Unspecified