Provider Demographics
NPI:1316004187
Name:NORTHWEST OPTOMETRY LLC
Entity Type:Organization
Organization Name:NORTHWEST OPTOMETRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:STUDEBAKER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:937-836-3041
Mailing Address - Street 1:639 W NATIONAL RD
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322-1155
Mailing Address - Country:US
Mailing Address - Phone:937-836-3041
Mailing Address - Fax:937-836-1937
Practice Address - Street 1:639 W NATIONAL RD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-1155
Practice Address - Country:US
Practice Address - Phone:937-836-3041
Practice Address - Fax:937-836-1937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3970152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH=========028Medicaid
OH=========027Medicaid
OH=========029Medicaid
OHT48793Medicare UPIN
OH=========028Medicaid
OHU20197Medicare UPIN
OH=========029Medicaid
OHU20197Medicare UPIN
OH0624701Medicare ID - Type Unspecified
OH=========029Medicaid