Provider Demographics
NPI:1073621264
Name:TITUS, AMY DAWN (OD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:DAWN
Last Name:TITUS
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 1:29610 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:WICKLIFFE
Mailing Address - State:OH
Mailing Address - Zip Code:44092-1829
Mailing Address - Country:US
Mailing Address - Phone:440-943-1993
Mailing Address - Fax:440-943-9595
Practice Address - Street 1:29610 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:WICKLIFFE
Practice Address - State:OH
Practice Address - Zip Code:44092-1829
Practice Address - Country:US
Practice Address - Phone:440-943-1993
Practice Address - Fax:440-943-9595
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5246152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2327986Medicaid
OH341194090027OtherCARE SOURCE
OH000000238954OtherANTHEM
OH000000238954OtherANTHEM