Healthcare Provider Details

I. General information

NPI: 1487646816
Provider Name (Legal Business Name): PHILIP W VALENTINE OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 09/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

739 SPRUCE AVE
SIDNEY OH
45365-0179
US

IV. Provider business mailing address

PO BOX 179
SIDNEY OH
45365-0179
US

V. Phone/Fax

Practice location:
  • Phone: 937-492-1990
  • Fax: 937-492-7230
Mailing address:
  • Phone: 937-492-1990
  • Fax: 937-492-7230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2815T1994
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: