Provider Demographics
NPI:1467476069
Name:OHIO RETINA ASSOCIATES, INC.
Entity Type:Organization
Organization Name:OHIO RETINA ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-966-9800
Mailing Address - Street 1:4690 MUNSON ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-3636
Mailing Address - Country:US
Mailing Address - Phone:330-966-9800
Mailing Address - Fax:330-966-9803
Practice Address - Street 1:340 OXFORD ST STE 210
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622-1967
Practice Address - Country:US
Practice Address - Phone:330-602-8351
Practice Address - Fax:330-602-7500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0149904Medicaid
OHDE4090OtherRAILROAD MEDICARE
OH0149904Medicaid