Basic Information
| Provider Information | |||||||||
| NPI: | 1538471172 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSAL | ||||||||
| FirstName: | SOBY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E OLNEY AVENUE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191202421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154567000 | ||||||||
| FaxNumber: | 2154565926 | ||||||||
| Practice Location | |||||||||
| Address1: | 5401 OLD YORK RD | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191413030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154567000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2010 | ||||||||
| LastUpdateDate: | 02/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 27OA00625100 | NJ | N | Eye and Vision Services Providers | Optometrist | 152W00000X | OEG002457 | PA | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.