Provider Demographics
NPI:1528230711
Name:ERIE OPTICAL
Entity Type:Organization
Organization Name:ERIE OPTICAL
Other - Org Name:ROBERT WALDMAN OD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCHANAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-255-7727
Mailing Address - Street 1:8900 MENTOR AVE
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-6345
Mailing Address - Country:US
Mailing Address - Phone:440-255-7727
Mailing Address - Fax:440-255-4288
Practice Address - Street 1:8900 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-6345
Practice Address - Country:US
Practice Address - Phone:440-255-7727
Practice Address - Fax:440-255-4288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3382152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0524290001Medicare NSC
OHT48139Medicare UPIN
OH0561433Medicare PIN
OH9332351Medicare PIN