Provider Demographics
NPI:1295820520
Name:FRAGOULIS, MARIA JEANETTE (OD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:JEANETTE
Last Name:FRAGOULIS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 S SPRING RD
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-2444
Mailing Address - Country:US
Mailing Address - Phone:614-209-8880
Mailing Address - Fax:614-901-9132
Practice Address - Street 1:8659 COLUMBUS PIKE
Practice Address - Street 2:
Practice Address - City:LEWIS CENTER
Practice Address - State:OH
Practice Address - Zip Code:43035-9699
Practice Address - Country:US
Practice Address - Phone:740-657-1301
Practice Address - Fax:740-657-8442
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4104152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist