Provider Demographics
NPI:1689030413
Name:RAHARDJANOTO, LAURENCE (OD)
Entity Type:Individual
Prefix:
First Name:LAURENCE
Middle Name:
Last Name:RAHARDJANOTO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1584 STRINGTOWN RD
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-9832
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1584 STRINGTOWN RD
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-9832
Practice Address - Country:US
Practice Address - Phone:626-321-8548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-08
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOPT.6429152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist