Healthcare Provider Details

I. General information

NPI: 1457520553
Provider Name (Legal Business Name): DONCH AND BAKER, O.D. EYE DOCTORS OF MADISON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2008
Last Update Date: 09/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 N LAKE ST
MADISON OH
44057-3115
US

IV. Provider business mailing address

103 N LAKE ST
MADISON OH
44057-3115
US

V. Phone/Fax

Practice location:
  • Phone: 440-428-2526
  • Fax: 440-428-2526
Mailing address:
  • Phone: 440-428-2526
  • Fax: 440-428-2526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: NICK J DONCH
Title or Position: OWNER
Credential: OD
Phone: 440-428-2526