Provider Demographics
NPI:1699973677
Name:VAN WERT VISION LTD
Entity type:Organization
Organization Name:VAN WERT VISION LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:BIDLACK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:419-238-9244
Mailing Address - Street 1:1183 WESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:VAN WERT
Mailing Address - State:OH
Mailing Address - Zip Code:45891-2464
Mailing Address - Country:US
Mailing Address - Phone:419-238-9244
Mailing Address - Fax:419-238-4695
Practice Address - Street 1:1183 WESTWOOD DR
Practice Address - Street 2:
Practice Address - City:VAN WERT
Practice Address - State:OH
Practice Address - Zip Code:45891-2464
Practice Address - Country:US
Practice Address - Phone:419-238-9244
Practice Address - Fax:419-238-4695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3921/T1214152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH152WOOOOOXOtherTAXONOMY
OH152WOOOOOXOtherTAXONOMY
OHDB6791Medicare PIN
OHVA9341031Medicare PIN