Healthcare Provider Details

I. General information

NPI: 1972834307
Provider Name (Legal Business Name): WILLIAM KEGERIZE OD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2010
Last Update Date: 09/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 MAIN ST
GENOA OH
43430-1635
US

IV. Provider business mailing address

603 MAIN ST
GENOA OH
43430-1635
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License NumberOH5558
License Number StateOH

VIII. Authorized Official

Name: DR. WILLIAM R KEGERIZE
Title or Position: OWNER
Credential: O.D.
Phone: 419-855-3640