Provider Demographics
NPI:1316902331
Name:GRADISEK, ROBERT F (OD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:F
Last Name:GRADISEK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1142 W 37TH ST
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44052-5115
Mailing Address - Country:US
Mailing Address - Phone:440-282-6669
Mailing Address - Fax:440-282-5397
Practice Address - Street 1:1142 W 37TH ST
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44052-5115
Practice Address - Country:US
Practice Address - Phone:440-282-6669
Practice Address - Fax:440-282-5397
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3172 T921152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0525712OtherMEDICARE PTAN
OH4100043904OtherRAILROAD MEDICARE PIN
OH0525712Medicare PIN
OH4100043904OtherRAILROAD MEDICARE PIN