=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598985400
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIBERTY OPTHALMOLOGY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2007
-----------------------------------------------------
Last Update Date | 12/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27 CLAIREDAN DR
-----------------------------------------------------
City | POWELL
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43065-8064
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-841-9300
-----------------------------------------------------
Fax | 614-841-9319
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27 CLAIREDAN DR
-----------------------------------------------------
City | POWELL
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43065-8064
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-841-9300
-----------------------------------------------------
Fax | 614-841-9319
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ERIC WILLIAMS LOTHES
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 614-841-9300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 35 055417
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------