Provider Demographics
NPI:1306847157
Name:KEGERIZE, WILLIAM (OD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:KEGERIZE
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 1:1606 DIER RD
Mailing Address - Street 2:
Mailing Address - City:CURTICE
Mailing Address - State:OH
Mailing Address - Zip Code:43412-9702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:603 MAIN ST
Practice Address - Street 2:
Practice Address - City:GENOA
Practice Address - State:OH
Practice Address - Zip Code:43430-1635
Practice Address - Country:US
Practice Address - Phone:419-855-3640
Practice Address - Fax:419-855-4743
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5558152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5558OtherSTATE LICENSE NUMBER
OH3037403Medicaid
OHP01300310OtherRAILROAD MEDICARE
OH3037403Medicaid