Healthcare Provider Details

I. General information

NPI: 1013605542
Provider Name (Legal Business Name): ROBERT RUSSELL WHITE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2023
Last Update Date: 04/24/2023
Certification Date: 04/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8451 COLERAIN AVE
CINCINNATI OH
45239-3926
US

IV. Provider business mailing address

8451 COLERAIN AVE
CINCINNATI OH
45239-3926
US

V. Phone/Fax

Practice location:
  • Phone: 513-923-3202
  • Fax:
Mailing address:
  • Phone: 513-923-3202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberOP.013904-SC
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: