Healthcare Provider Details

I. General information

NPI: 1306847157
Provider Name (Legal Business Name): WILLIAM KEGERIZE OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 01/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 MAIN ST
GENOA OH
43430-1635
US

IV. Provider business mailing address

1606 DIER RD
CURTICE OH
43412-9702
US

V. Phone/Fax

Practice location:
  • Phone: 419-855-3640
  • Fax: 419-855-4743
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5558
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: