MEDICARE: NEWARK OPTOMETRY 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	0H5165	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

General Provider Information

NPI Number	:	1841312139
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEWARK OPTOMETRY LLC

Provider Business Mailing Address
First Line	:	603 COUNTRY CLUB DR
Second Line	:
City	:	NEWARK
State	:	OH
Zip	:	43055-2154
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	603 COUNTRY CLUB DR
Second Line	:
City	:	NEWARK
State	:	OH
Zip	:	43055-2154
Country	:	US
Telephone Number	:	740-344-1312
Fax Number	:

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	KATHRYN SOVINE
Credential	:
Telephone Number	:	740-344-1312

Provider Enumeration Date	:	04/06/2007
Last Update Date	:	05/12/2010

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Directions to “NEWARK OPTOMETRY LLC ” Practice Location

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