Basic Information
| Provider Information | |||||||||
| NPI: | 1982755757 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE GLAUCOMA CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 PARK WEST BLVD | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443204218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308368545 | ||||||||
| FaxNumber: | 3308368598 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 PARK WEST BLVD | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443204218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308368545 | ||||||||
| FaxNumber: | 3308368598 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WOODRUFF | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3308368545 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 35050864 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0557651 | 05 | OH | MEDICAID |