Provider Demographics
NPI:1295848133
Name:YOUSHAK, ISADORE JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:ISADORE
Middle Name:JOHN
Last Name:YOUSHAK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:ISADORE
Other - Middle Name:JOHN
Other - Last Name:YOUSHAK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 276
Mailing Address - Street 2:15795 W HIGH ST
Mailing Address - City:MIDDLEFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44062
Mailing Address - Country:US
Mailing Address - Phone:440-632-0194
Mailing Address - Fax:440-632-0194
Practice Address - Street 1:15795 W HIGH ST
Practice Address - Street 2:
Practice Address - City:MIDDLEFIELD
Practice Address - State:OH
Practice Address - Zip Code:44062
Practice Address - Country:US
Practice Address - Phone:440-632-0194
Practice Address - Fax:440-632-0194
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2777T980152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0132181Medicaid
T46210Medicare UPIN
OH0132181Medicaid
OH0368681Medicare PIN