Provider Demographics
NPI:1588612089
Name:WARNER, JONATHAN L (OD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:L
Last Name:WARNER
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 635
Mailing Address - Street 2:
Mailing Address - City:KENTON
Mailing Address - State:OH
Mailing Address - Zip Code:43326-0635
Mailing Address - Country:US
Mailing Address - Phone:419-673-0492
Mailing Address - Fax:
Practice Address - Street 1:110 N HIGH ST
Practice Address - Street 2:
Practice Address - City:KENTON
Practice Address - State:OH
Practice Address - Zip Code:43326-1549
Practice Address - Country:US
Practice Address - Phone:419-673-0492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4240/T977152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0869369Medicaid
OHP00076808OtherRAILROAD MEDICARE #
OHWA0675462Medicare PIN
OHP00076808OtherRAILROAD MEDICARE #