Provider Demographics
NPI:1073785119
Name:PHILLIP KEYSOR
Entity Type:Organization
Organization Name:PHILLIP KEYSOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:KEYSOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-935-1505
Mailing Address - Street 1:219 CRESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WILLARD
Mailing Address - State:OH
Mailing Address - Zip Code:44890-1650
Mailing Address - Country:US
Mailing Address - Phone:419-935-1505
Mailing Address - Fax:419-933-7071
Practice Address - Street 1:219 CRESTWOOD DR
Practice Address - Street 2:
Practice Address - City:WILLARD
Practice Address - State:OH
Practice Address - Zip Code:44890-1650
Practice Address - Country:US
Practice Address - Phone:419-935-1505
Practice Address - Fax:419-933-7071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-28
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2984T512152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0804270001Medicare NSC