Provider Demographics
NPI:1821164310
Name:SIPPLE, BERNADETTE (OD)
Entity Type:Individual
Prefix:DR
First Name:BERNADETTE
Middle Name:
Last Name:SIPPLE
Suffix:
Gender:F
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:PO BOX 880
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44236-5880
Mailing Address - Country:US
Mailing Address - Phone:330-697-4748
Mailing Address - Fax:866-425-2239
Practice Address - Street 1:3177 WESTGATE MALL
Practice Address - Street 2:
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126
Practice Address - Country:US
Practice Address - Phone:330-697-4748
Practice Address - Fax:866-425-2239
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4469152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHU44084Medicare UPIN