Healthcare Provider Details

I. General information

NPI: 1730316340
Provider Name (Legal Business Name): GERALDJ.D'AGOSTINO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2009
Last Update Date: 06/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5404 NORTHFIELD RD
MAPLE HEIGHTS OH
44137-3113
US

IV. Provider business mailing address

150 MALLARD CREEK RUN
LAGRANGE OH
44050-9802
US

V. Phone/Fax

Practice location:
  • Phone: 216-587-6620
  • Fax: 216-587-6623
Mailing address:
  • Phone: 440-458-6272
  • Fax: 440-458-6272

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: DR. GERALD J D'AGOSTINO
Title or Position: OWNER
Credential: OD
Phone: 216-587-6620