Provider Demographics
NPI:1386057941
Name:WIZARD OF EYES, INC
Entity type:Organization
Organization Name:WIZARD OF EYES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DESMON
Authorized Official - Last Name:ROUDEBUSH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:614-619-7973
Mailing Address - Street 1:2725 S HAMILTON RD
Mailing Address - Street 2:G-5
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43232-4904
Mailing Address - Country:US
Mailing Address - Phone:614-863-0195
Mailing Address - Fax:614-863-2701
Practice Address - Street 1:9878 BREWSTER LN
Practice Address - Street 2:BOX 108
Practice Address - City:POWELL
Practice Address - State:OH
Practice Address - Zip Code:43065-7980
Practice Address - Country:US
Practice Address - Phone:614-619-7973
Practice Address - Fax:614-789-6399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-11
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5771152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0102912Medicaid