Provider Demographics
NPI:1710151071
Name:JOHN R LOESCH OD
Entity Type:Organization
Organization Name:JOHN R LOESCH OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:LOESCH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:937-278-5689
Mailing Address - Street 1:3721 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45405
Mailing Address - Country:US
Mailing Address - Phone:937-278-5689
Mailing Address - Fax:937-278-6781
Practice Address - Street 1:3721 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405
Practice Address - Country:US
Practice Address - Phone:937-278-5689
Practice Address - Fax:937-278-6781
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOHN R LOESCH OD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-17
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3184T545152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0332689Medicaid
0614210001Medicare NSC
LO0445281Medicare PIN
OH0332689Medicaid