Healthcare Provider Details

I. General information

NPI: 1568542173
Provider Name (Legal Business Name): JOHN R GWIN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 01/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5180 E MAIN ST SUITE F
COLUMBUS OH
43213-2436
US

IV. Provider business mailing address

160 N TOWNSHIP RD
PATASKALA OH
43062-9192
US

V. Phone/Fax

Practice location:
  • Phone: 614-866-9002
  • Fax: 614-866-3581
Mailing address:
  • Phone: 740-501-5577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5311-T2220
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: