Provider Demographics
NPI:1386642049
Name:CERTIFIED ORTHOTIC & PROSTHETIC, INC
Entity Type:Organization
Organization Name:CERTIFIED ORTHOTIC & PROSTHETIC, INC
Other - Org Name:CUSTOM DESIGN ORTHOTIC & PROSTHETIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PRACTITIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:MARSHALL
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:LPO
Authorized Official - Phone:740-383-3490
Mailing Address - Street 1:1136 INDEPENDENCE AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-6318
Mailing Address - Country:US
Mailing Address - Phone:740-383-3490
Mailing Address - Fax:740-383-6459
Practice Address - Street 1:1136 INDEPENDENCE AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-6318
Practice Address - Country:US
Practice Address - Phone:740-383-3490
Practice Address - Fax:740-383-6459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPO144335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0256431Medicaid
OH1112930001Medicare ID - Type Unspecified