Healthcare Provider Details

I. General information

NPI: 1366529844
Provider Name (Legal Business Name): DAVID A. NIEDERKOHR O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 05/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 NORTHWOOD DR
DELAWARE OH
43015-1501
US

IV. Provider business mailing address

10197 ABBOTTS WAY
POWELL OH
43065-6652
US

V. Phone/Fax

Practice location:
  • Phone: 740-369-7701
  • Fax: 740-369-0021
Mailing address:
  • Phone: 614-785-9858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3260T1062
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: