Provider Demographics
NPI:1073659512
Name:WOLOSCHAK, MICHAEL J (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:WOLOSCHAK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2670 SOUTH RACCOON STE 1
Mailing Address - Street 2:
Mailing Address - City:AUSTINTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-5344
Mailing Address - Country:US
Mailing Address - Phone:330-799-3937
Mailing Address - Fax:330-799-1557
Practice Address - Street 1:2670 SOUTH RACCOON STE 1
Practice Address - Street 2:
Practice Address - City:AUSTINTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-5344
Practice Address - Country:US
Practice Address - Phone:330-799-3937
Practice Address - Fax:330-799-1557
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3579T706152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2200637OtherUHC MEDICARE COMPLETE
OH000000142252OtherANTHEM
OH0560576Medicaid
OH2200637OtherUNITED HEALTH CARE
OH341923934027OtherCARESOURCE
OH341923934OtherUNISON
OH410047096OtherRAILROAD MEDICARE
OH0560576Medicaid
OH0152200001Medicare NSC
OH410047096OtherRAILROAD MEDICARE