MEDICARE: PHYLLIS VISOCAN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	35036423	OH
2	207W00000X	Ophthalmology Physician	4301034155	MI
3	207W00000X	Ophthalmology Physician	G29024	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	34330690	OTHER	OH	LABCORP

General Provider Information

NPI Number	:	1710050141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHYLLIS VISOCAN M.D.

Provider Business Mailing Address
First Line	:	1669 W LANE AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43221-3339
Country	:	US
Telephone Number	:	614-487-1212
Fax Number	:	614-487-1141

Provider Business Practice Location Address
First Line	:	1669 W LANE AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43221-3339
Country	:	US
Telephone Number	:	614-487-1212
Fax Number	:	614-487-1141

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	07/09/2007

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Directions to “ PHYLLIS VISOCAN M.D.” Practice Location

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