Healthcare Provider Details

I. General information

NPI: 1487622593
Provider Name (Legal Business Name): PHILIP RABER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12990 EMERSON RD.
KIDRON OH
44636-0010
US

IV. Provider business mailing address

PO BOX 10
KIDRON OH
44636-0010
US

V. Phone/Fax

Practice location:
  • Phone: 330-857-0123
  • Fax: 330-857-0246
Mailing address:
  • Phone: 330-857-0123
  • Fax: 330-857-0246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4582
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: