Healthcare Provider Details

I. General information

NPI: 1588770556
Provider Name (Legal Business Name): PAUL A. SPEROS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3360 NEW GERMANY TREBEIN RD
BEAVERCREEK OH
45431-1702
US

IV. Provider business mailing address

6233 AGENBROAD RD
TIPP CITY OH
45371-8760
US

V. Phone/Fax

Practice location:
  • Phone: 937-426-4638
  • Fax: 937-426-3627
Mailing address:
  • Phone: 937-543-3930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number3834/T1279
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: