Provider Demographics
NPI:1710900683
Name:OHIO STATE UNIVERSITY
Entity Type:Organization
Organization Name:OHIO STATE UNIVERSITY
Other - Org Name:THE OHIO STATE UNIVERSITY COLLEGE OF OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSOCIATE DEAN OF CLINIC SERVICES
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:J
Authorized Official - Last Name:NIXON
Authorized Official - Suffix:
Authorized Official - Credentials:OD, FAAO
Authorized Official - Phone:614-292-5367
Mailing Address - Street 1:1664 NEIL AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43201-2333
Mailing Address - Country:US
Mailing Address - Phone:614-292-2020
Mailing Address - Fax:614-247-4543
Practice Address - Street 1:1664 NEIL AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43201-2333
Practice Address - Country:US
Practice Address - Phone:614-292-2020
Practice Address - Fax:614-247-4543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6543600Medicaid
WV3810007816Medicaid
OH6543600Medicaid
OHP00232788Medicare PIN