Healthcare Provider Details

I. General information

NPI: 1881698751
Provider Name (Legal Business Name): JEFFERY L. MOREHEAD O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 12/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 MIDWAY MALL
ELYRIA OH
44035-2468
US

IV. Provider business mailing address

123 BARKWOOD DR
WADSWORTH OH
44281-8736
US

V. Phone/Fax

Practice location:
  • Phone: 440-324-5861
  • Fax:
Mailing address:
  • Phone: 330-336-6878
  • Fax: 330-334-6061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3038/T1523
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: