Provider Demographics
NPI:1386382877
Name:GERSHOM, MACKENZIE MAY (OD)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:MAY
Last Name:GERSHOM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1299 TANSY CT
Mailing Address - Street 2:
Mailing Address - City:TALLMADGE
Mailing Address - State:OH
Mailing Address - Zip Code:44278-2678
Mailing Address - Country:US
Mailing Address - Phone:330-786-7857
Mailing Address - Fax:
Practice Address - Street 1:5965 E BROAD ST STE 480
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-1562
Practice Address - Country:US
Practice Address - Phone:614-751-4070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-24
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOPT.007062152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist