Provider Demographics
NPI:1144293911
Name:NOLL, JON ERIC (OD)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:ERIC
Last Name:NOLL
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 1:1440 STATE RD
Mailing Address - Street 2:
Mailing Address - City:DUNCANNON
Mailing Address - State:PA
Mailing Address - Zip Code:17020-9551
Mailing Address - Country:US
Mailing Address - Phone:717-957-4224
Mailing Address - Fax:717-957-4966
Practice Address - Street 1:1440 STATE RD
Practice Address - Street 2:
Practice Address - City:DUNCANNON
Practice Address - State:PA
Practice Address - Zip Code:17020-9551
Practice Address - Country:US
Practice Address - Phone:717-957-4224
Practice Address - Fax:717-957-4966
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001572152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
410002052OtherTRAVELERS MEDICARE
401689OtherHIGHMARK BLUE SHIELD
PA0151860001Medicare PIN
401689OtherHIGHMARK BLUE SHIELD
410002052OtherTRAVELERS MEDICARE
PA401689Medicare ID - Type Unspecified