MEDICARE: DR. NATHAN DAVID BORNTRAGER 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	5845	OH

General Provider Information

NPI Number	:	1356570691
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NATHAN DAVID BORNTRAGER O.D

Provider Business Mailing Address
First Line	:	4820 EVERHARD RD NW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44718-2413
Country	:	US
Telephone Number	:	330-526-8322
Fax Number	:

Provider Business Practice Location Address
First Line	:	4820 EVERHARD RD NW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44718-2413
Country	:	US
Telephone Number	:	330-526-8322
Fax Number	:

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

Provider Enumeration Date	:	07/08/2009
Last Update Date	:	03/31/2015

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