Provider Demographics
NPI:1316637721
Name:MITSYUK, YAROSLAV
Entity type:Individual
Prefix:
First Name:YAROSLAV
Middle Name:
Last Name:MITSYUK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 TALLMADGE RD
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-7204
Mailing Address - Country:US
Mailing Address - Phone:330-673-3516
Mailing Address - Fax:
Practice Address - Street 1:250 TALLMADGE RD
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-7204
Practice Address - Country:US
Practice Address - Phone:330-673-3516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOP.017409-S156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician