Provider Demographics
NPI:1710102751
Name:MID OHIO NEURO OPHTHALMOLOGY AND NEURO OTOLOGY INC
Entity Type:Organization
Organization Name:MID OHIO NEURO OPHTHALMOLOGY AND NEURO OTOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD JD
Authorized Official - Phone:740-452-4053
Mailing Address - Street 1:751 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-2868
Mailing Address - Country:US
Mailing Address - Phone:740-452-4053
Mailing Address - Fax:740-452-4580
Practice Address - Street 1:751 FOREST AVE
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-2868
Practice Address - Country:US
Practice Address - Phone:740-452-4053
Practice Address - Fax:740-452-4580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350829332084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2144807Medicaid
OH2144807Medicaid