Healthcare Provider Details

I. General information

NPI: 1780642439
Provider Name (Legal Business Name): CLINT PAXSON O.D. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 06/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28112 CHARDON RD
WILLOUGHBY HILLS OH
44092-2710
US

IV. Provider business mailing address

28112 CHARDON RD
WILLOUGHBY HILLS OH
44092-2710
US

V. Phone/Fax

Practice location:
  • Phone: 440-944-8333
  • Fax: 440-944-3632
Mailing address:
  • Phone: 440-944-8333
  • Fax: 440-944-3632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5566 T2480
License Number StateOH

VIII. Authorized Official

Name: DR. CLINT D PAXSON
Title or Position: OWNER
Credential: O.D.
Phone: 440-944-8333