Provider Demographics
NPI:1568490738
Name:RILEY, JOEL S (OD)
Entity Type:Individual
Prefix:DR
First Name:JOEL
Middle Name:S
Last Name:RILEY
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 1:4139 FULTON DR NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2819
Mailing Address - Country:US
Mailing Address - Phone:330-966-2400
Mailing Address - Fax:330-966-0114
Practice Address - Street 1:4139 FULTON DR NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2819
Practice Address - Country:US
Practice Address - Phone:330-966-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3263/T154152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI0470892Medicare UPIN
JO9932541Medicare ID - Type UnspecifiedMEDICARE PROVIDER
T47089Medicare UPIN
OH0260390001Medicare NSC