Provider Demographics
NPI:1609975846
Name:HAKIM, EDMOND ROGER (OD)
Entity Type:Individual
Prefix:DR
First Name:EDMOND
Middle Name:ROGER
Last Name:HAKIM
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 1:254 NORTON AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BARBERTON
Mailing Address - State:OH
Mailing Address - Zip Code:44203-1932
Mailing Address - Country:US
Mailing Address - Phone:330-753-2004
Mailing Address - Fax:330-753-2004
Practice Address - Street 1:254 NORTON AVE STE 1
Practice Address - Street 2:
Practice Address - City:BARBERTON
Practice Address - State:OH
Practice Address - Zip Code:44203-1932
Practice Address - Country:US
Practice Address - Phone:330-753-2004
Practice Address - Fax:330-753-2004
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3802152W00000X
OH003802-T842152W00000X
OH3802-T842152WC0802X, 152WP0200X, 152WV0400X, 152WX0102X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0595020Medicaid
OH1632590400OtherCIGNA
OH34-1531581OtherSUMMA HEALTHCARE
OH341531581-001OtherMEDICAL MUTUAL
OH000000133457OtherOHIO BC BS
OHQ015690OtherHEALTH PLAN
OH1609975846OtherOPTOMETRIC SERVICES
OH1609975846OtherCARESOURCE
OH34-1531581OtherHOMETOWN HEALTHCARE
OH000000166347OtherANTHEM
OH2200596OtherUNITED HEALTHCARE
OH000000133457OtherANTHEM