Provider Demographics
NPI:1558553784
Name:ROSE B. DICKERHOOF, O.D.,INC.
Entity Type:Organization
Organization Name:ROSE B. DICKERHOOF, O.D.,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES.
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:B
Authorized Official - Last Name:DICKERHOOF
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:330-725-4464
Mailing Address - Street 1:837 N COURT ST
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-1718
Mailing Address - Country:US
Mailing Address - Phone:330-725-4464
Mailing Address - Fax:
Practice Address - Street 1:837 N COURT ST
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-1718
Practice Address - Country:US
Practice Address - Phone:330-725-4464
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-12
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3791152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9335411Medicare PIN
OH0310660001Medicare NSC