MEDICARE: COLUMBUS EYEWORKS LLC

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	3759/T520	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	293522321008	OTHER	OH	MEDICAL MUTUAL OF OHIO PIN
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	000000134652	OTHER	OH	BLUE CROSS/BLUE SHIELD PIN
4	1669545042	OTHER	OH	INDIVIDUAL NPI (TYPE 1) FOR DANIEL J. KOCH, O.D.
5	4628497	OTHER	OH	AETNA PIN

General Provider Information

NPI Number	:	1689849549
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLUMBUS EYEWORKS LLC

Provider Business Mailing Address
First Line	:	1127 N HIGH ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43201-2441
Country	:	US
Telephone Number	:	614-421-2020
Fax Number	:	614-421-9115

Provider Business Practice Location Address
First Line	:	25 W HUBBARD AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43215-1410
Country	:	US
Telephone Number	:	614-421-2020
Fax Number	:	614-421-9115

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KURT BENNETT
Credential	:	OD
Telephone Number	:	614-421-2020

Provider Enumeration Date	:	04/22/2008
Last Update Date	:	12/04/2025

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1174878987 — MR. MARK LEVERNE SIMPSON LICDC
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Directions to “COLUMBUS EYEWORKS LLC ” Practice Location

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