=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760189476
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMILY HERENDEEN OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2023
-----------------------------------------------------
Last Update Date | 08/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1595 GEORGESVILLE SQUARE DR
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43228-3689
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-385-0088
-----------------------------------------------------
Fax | 614-385-0088
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1595 GEORGESVILLE SQUARE DR
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43228-3689
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-385-0088
-----------------------------------------------------
Fax | 614-385-0088
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 4901005660
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT.007324
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------