Basic Information
Provider Information | |||||||||
NPI: | 1528096203 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OHIO VISION OF TOLEDO INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | OPTIVUE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2740 NAVARRE AVE | ||||||||
Address2: |   | ||||||||
City: | OREGON | ||||||||
State: | OH | ||||||||
PostalCode: | 436163216 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4196934444 | ||||||||
FaxNumber: | 4196972149 | ||||||||
Practice Location | |||||||||
Address1: | 2740 NAVARRE AVE | ||||||||
Address2: |   | ||||||||
City: | OREGON | ||||||||
State: | OH | ||||||||
PostalCode: | 436163216 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4196934444 | ||||||||
FaxNumber: | 4196972149 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/29/2006 | ||||||||
LastUpdateDate: | 01/23/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MARTIN | ||||||||
AuthorizedOfficialFirstName: | WILLIAM | ||||||||
AuthorizedOfficialMiddleName: | G. | ||||||||
AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 4196934444 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 2673085 | 05 | OH |   | MEDICAID | 2190657 | 01 | OH | UNITED HEALTH CARE | OTHER | 4559068 | 01 | OH | AETNA | OTHER |