Provider Demographics
NPI:1609880624
Name:ACKERSON, LAIRD DOUGLAS (OD)
Entity Type:Individual
Prefix:DR
First Name:LAIRD
Middle Name:DOUGLAS
Last Name:ACKERSON
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 1:4555 CEMETERY RD
Mailing Address - Street 2:
Mailing Address - City:HILLIARD
Mailing Address - State:OH
Mailing Address - Zip Code:43026-1102
Mailing Address - Country:US
Mailing Address - Phone:614-876-4044
Mailing Address - Fax:614-876-0255
Practice Address - Street 1:4555 CEMETERY RD
Practice Address - Street 2:
Practice Address - City:HILLIARD
Practice Address - State:OH
Practice Address - Zip Code:43026-1102
Practice Address - Country:US
Practice Address - Phone:614-876-4044
Practice Address - Fax:614-876-0255
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2009-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3586/T1086152W00000X, 152WC0802X, 152WP0200X, 152WS0006X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00289883OtherRAILROAD MEDICARE B PIN
OH000000323515OtherANTHEM BC/BS PROVIDER
OH04-3743736OtherFED TAX ID
OHDE3942OtherRAILROAD MEDICARE GRP NO.
OH2200005OtherUNITED HEATHCARE PROVIDER
OHP00289883OtherRAILROAD MEDICARE B PIN
OH5072780001Medicare NSC