Provider Demographics
NPI:1235135807
Name:GAETANO, H ROBERT (OD)
Entity Type:Individual
Prefix:
First Name:H
Middle Name:ROBERT
Last Name:GAETANO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:HENRY
Other - Middle Name:ROBERT
Other - Last Name:GAETANO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:3155 CANFIELD RD
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44511-2880
Mailing Address - Country:US
Mailing Address - Phone:330-792-4923
Mailing Address - Fax:330-792-2382
Practice Address - Street 1:3155 CANFIELD RD
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44511-2880
Practice Address - Country:US
Practice Address - Phone:330-792-4923
Practice Address - Fax:330-792-2382
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4106 T831152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0775675Medicaid
OH0644554Medicare ID - Type Unspecified
OH0775675Medicaid