Provider Demographics
NPI:1780642439
Name:CLINT PAXSON O.D. LLC
Entity Type:Organization
Organization Name:CLINT PAXSON O.D. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:D
Authorized Official - Last Name:PAXSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:440-944-8333
Mailing Address - Street 1:28112 CHARDON RD
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44092-2710
Mailing Address - Country:US
Mailing Address - Phone:440-944-8333
Mailing Address - Fax:440-944-3632
Practice Address - Street 1:28112 CHARDON RD
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY HILLS
Practice Address - State:OH
Practice Address - Zip Code:44092-2710
Practice Address - Country:US
Practice Address - Phone:440-944-8333
Practice Address - Fax:440-944-3632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5566 T2480152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2630111Medicaid
OH9360221Medicare PIN