Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 152WC0802X | Optometrist | Corneal and Contact Management | 2756 T356 | OHIO | No |
| 2 | 152WS0006X | Optometrist | Sports Vision | 2756 T356 | OHIO | No |
| 3 | 152W00000X | Optometrist | | 2756 T356 | OHIO | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 000000116894 | OTHER | OHIO | ANTHEM BC/BS PROVIDER ID# |
| 2 | 2200043 | OTHER | OHIO | UNITED HEALTHCARE ID# |
| 3 | 946058 | OTHER | OHIO | AETNA INS. PROVIDER ID# |
| 4 | 0699070 | MEDICAID | OHIO | |
| 5 | BI0157743 | MEDICARE PIN | OHIO | |
| 6 | 0286870002 | OTHER | OHIO | DMESN |
| 7 | 0286870001 | MEDICARE NSC | OHIO | |
| 8 | T46106 | MEDICARE UPIN | OHIO | |
| 9 | BI0157744 | MEDICARE PIN | OHIO | |
