Provider Demographics
NPI:1386601193
Name:EYE SURGEON ASSOCIATES, INC.
Entity type:Organization
Organization Name:EYE SURGEON ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:H
Authorized Official - Last Name:O'DONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-782-6588
Mailing Address - Street 1:1490 PINEHURST DR
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-8670
Mailing Address - Country:US
Mailing Address - Phone:419-782-6588
Mailing Address - Fax:419-784-3622
Practice Address - Street 1:1490 PINEHURST DR
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-8670
Practice Address - Country:US
Practice Address - Phone:419-782-6588
Practice Address - Fax:419-784-3622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35063310207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0922381Medicaid
OH0922381Medicaid
OHF27527Medicare UPIN