Provider Demographics
NPI:1780686873
Name:RILES, HOLBROOK JR (OD)
Entity Type:Individual
Prefix:
First Name:HOLBROOK
Middle Name:
Last Name:RILES
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:949 STATE ROUTE #314 SOUTH
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-7797
Mailing Address - Country:US
Mailing Address - Phone:419-756-7295
Mailing Address - Fax:419-756-7574
Practice Address - Street 1:2485 POSSUM RUN RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-9447
Practice Address - Country:US
Practice Address - Phone:419-756-7295
Practice Address - Fax:419-756-7574
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3710/P1203152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0546172Medicaid
OHHO0543294Medicare PIN