Healthcare Provider Details

I. General information

NPI: 1598110140
Provider Name (Legal Business Name): ELIZABETH WALSH CZIRR O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2016
Last Update Date: 03/15/2022
Certification Date: 03/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 GRAND AVE
NEWPORT KY
41071-2570
US

IV. Provider business mailing address

PO BOX 635283
CINCINNATI OH
45263-5283
US

V. Phone/Fax

Practice location:
  • Phone: 859-781-3110
  • Fax: 859-441-1418
Mailing address:
  • Phone: 859-344-5555
  • Fax: 859-344-5552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3231
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2263DT
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: