Healthcare Provider Details

I. General information

NPI: 1568462174
Provider Name (Legal Business Name): ELIZABETH MUCKLEY O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 12/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2013 STATE ROUTE 59
KENT OH
44240-4113
US

IV. Provider business mailing address

2013 STATE ROUTE 59
KENT OH
44240-4113
US

V. Phone/Fax

Practice location:
  • Phone: 330-678-0201
  • Fax: 330-678-4272
Mailing address:
  • Phone: 330-678-0201
  • Fax: 330-678-4272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4833
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: