Provider Demographics
NPI:1134299704
Name:RADER, MICHAEL JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:RADER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6044 PARKMEADOW LN
Mailing Address - Street 2:SUITE B
Mailing Address - City:HILLIARD
Mailing Address - State:OH
Mailing Address - Zip Code:43026-7406
Mailing Address - Country:US
Mailing Address - Phone:614-876-2686
Mailing Address - Fax:614-876-2687
Practice Address - Street 1:6044 PARKMEADOW LN
Practice Address - Street 2:SUITE B
Practice Address - City:HILLIARD
Practice Address - State:OH
Practice Address - Zip Code:43026-7406
Practice Address - Country:US
Practice Address - Phone:614-876-2686
Practice Address - Fax:614-876-2687
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3303 T964152WC0802X
OHOH3303152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0366152Medicaid
OH410002935OtherRAILROAD MEDICARE
OH0366152Medicaid
OH0839280001Medicare NSC
OHRA0480591Medicare ID - Type Unspecified
OHT47165Medicare UPIN
OHRA0480591Medicare PIN