Provider Demographics
NPI:1487646816
Name:VALENTINE, PHILIP W (OD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:W
Last Name:VALENTINE
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:PO BOX 179
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365-0179
Mailing Address - Country:US
Mailing Address - Phone:937-492-1990
Mailing Address - Fax:937-492-7230
Practice Address - Street 1:739 SPRUCE AVE
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:OH
Practice Address - Zip Code:45365-0179
Practice Address - Country:US
Practice Address - Phone:937-492-1990
Practice Address - Fax:937-492-7230
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2815T1994152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY311195981OtherHUMANA
OH311195981026OtherCARESOURCE
OH0078679Medicaid
0351352Medicare ID - Type Unspecified
OH0078679Medicaid