Provider Demographics
NPI:1730316340
Name:GERALDJ.D'AGOSTINO
Entity Type:Organization
Organization Name:GERALDJ.D'AGOSTINO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:D'AGOSTINO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:216-587-6620
Mailing Address - Street 1:150 MALLARD CREEK RUN
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:OH
Mailing Address - Zip Code:44050-9802
Mailing Address - Country:US
Mailing Address - Phone:440-458-6272
Mailing Address - Fax:440-458-6272
Practice Address - Street 1:5404 NORTHFIELD RD
Practice Address - Street 2:
Practice Address - City:MAPLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44137-3113
Practice Address - Country:US
Practice Address - Phone:216-587-6620
Practice Address - Fax:216-587-6623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-22
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5369140001Medicare NSC