Provider Demographics
NPI:1225151277
Name:DANIEL R FRESON OD INC
Entity Type:Organization
Organization Name:DANIEL R FRESON OD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:FRESON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:216-771-8311
Mailing Address - Street 1:2012 W 25TH ST
Mailing Address - Street 2:ROOM 1
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44113-4135
Mailing Address - Country:US
Mailing Address - Phone:216-771-8311
Mailing Address - Fax:216-771-7450
Practice Address - Street 1:2012 W 25TH ST
Practice Address - Street 2:ROOM 1
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44113-4135
Practice Address - Country:US
Practice Address - Phone:216-771-8311
Practice Address - Fax:216-771-7450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH3347T441152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0489690Medicaid
OH0595061Medicare ID - Type Unspecified