Provider Demographics
NPI:1790785210
Name:EBERSOLE, KURT L (OD)
Entity Type:Individual
Prefix:DR
First Name:KURT
Middle Name:L
Last Name:EBERSOLE
Suffix:
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 1:15840 MEDICAL DRIVE SOUTH
Mailing Address - Street 2:SUITE A
Mailing Address - City:FINDLAY
Mailing Address - State:OH
Mailing Address - Zip Code:45840
Mailing Address - Country:US
Mailing Address - Phone:419-422-6190
Mailing Address - Fax:419-423-3235
Practice Address - Street 1:15840 MEDICAL DRIVE SOUTH
Practice Address - Street 2:SUITE A
Practice Address - City:FINDLAY
Practice Address - State:OH
Practice Address - Zip Code:45840
Practice Address - Country:US
Practice Address - Phone:419-422-6190
Practice Address - Fax:419-423-3235
Is Sole Proprietor?:No
Enumeration Date:2005-07-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3408152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000129592OtherANTHEM BC/BS
OH4628541OtherAETNA
OH3408OtherSTATE LICENSE
OH0893083Medicaid
OH0893083Medicaid
OH4628541OtherAETNA
OH0480931Medicare ID - Type UnspecifiedPPIN