Healthcare Provider Details

I. General information

NPI: 1831503630
Provider Name (Legal Business Name): JONATHAN JAY LYTLE O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2014
Last Update Date: 09/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

89 E WILSON BRIDGE RD
WORTHINGTON OH
43085-6315
US

IV. Provider business mailing address

89 E WILSON BRIDGE RD
WORTHINGTON OH
43085-6315
US

V. Phone/Fax

Practice location:
  • Phone: 614-885-7464
  • Fax:
Mailing address:
  • Phone: 614-885-7464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number6296
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: