Basic Information
| Provider Information | |||||||||
| NPI: | 1841307675 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CANTON OPTOMETRY CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4865 FRANK AVE NW | ||||||||
| Address2: | |||||||||
| City: | NORTH CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447207425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304941710 | ||||||||
| FaxNumber: | 3304945815 | ||||||||
| Practice Location | |||||||||
| Address1: | 4865 FRANK AVE NW | ||||||||
| Address2: | |||||||||
| City: | NORTH CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447207425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304941710 | ||||||||
| FaxNumber: | 3304945815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 04/15/2020 | ||||||||
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| AuthorizedOfficialLastName: | SHENDELAS | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 3304941710 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | 04/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WC0802X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management | 152W00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.