Provider Demographics
NPI:1366529844
Name:NIEDERKOHR, DAVID A (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
Last Name:NIEDERKOHR
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 1:10197 ABBOTTS WAY
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-6652
Mailing Address - Country:US
Mailing Address - Phone:614-785-9858
Mailing Address - Fax:
Practice Address - Street 1:25 NORTHWOOD DR
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-1501
Practice Address - Country:US
Practice Address - Phone:740-369-7701
Practice Address - Fax:740-369-0021
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3260T1062152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000117913OtherANTHEM BC/BS
OH17042OtherSPECTERA
OH311001012003OtherMEDICAL MUTUAL
3230OtherDAVIS VISION
OHOH1062OtherEYEMED
OH0349813Medicaid
0005353619OtherAETNA
OH0349813Medicaid
OH311001012OtherEIN
OH17042OtherSPECTERA
OHOH1062OtherEYEMED