MEDICARE: DR. AMY DAWN TITUS O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	5246	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	341194090027	OTHER	OH	CARE SOURCE
3	000000238954	OTHER	OH	ANTHEM

General Provider Information

NPI Number	:	1073621264
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMY DAWN TITUS O.D.

Provider Business Mailing Address
First Line	:	29610 EUCLID AVE
Second Line	:
City	:	WICKLIFFE
State	:	OH
Zip	:	44092-1829
Country	:	US
Telephone Number	:	440-943-1993
Fax Number	:	440-943-9595

Provider Business Practice Location Address
First Line	:	29610 EUCLID AVE
Second Line	:
City	:	WICKLIFFE
State	:	OH
Zip	:	44092-1829
Country	:	US
Telephone Number	:	440-943-1993
Fax Number	:	440-943-9595

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2006
Last Update Date	:	09/05/2007

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