Provider Demographics
NPI:1659343432
Name:DOSTALL, TIMOTHY ROBERT (OD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:ROBERT
Last Name:DOSTALL
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 1:411 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035
Mailing Address - Country:US
Mailing Address - Phone:440-323-5709
Mailing Address - Fax:
Practice Address - Street 1:411 EAST AVE
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035
Practice Address - Country:US
Practice Address - Phone:440-323-5709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-06
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3387T414152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0462495Medicaid
OH0462495Medicaid
0169630001Medicare NSC
OH0493822Medicare PIN