Provider Demographics
NPI:1902839368
Name:FRESON, DANIEL R (OD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:R
Last Name:FRESON
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 1:2012 W 25TH ST LBBY 1
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44113-4131
Mailing Address - Country:US
Mailing Address - Phone:216-771-8311
Mailing Address - Fax:216-771-7450
Practice Address - Street 1:2012 W 25TH ST LBBY 1
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44113-4131
Practice Address - Country:US
Practice Address - Phone:216-771-8311
Practice Address - Fax:216-771-7450
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3347 T 441152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0489690Medicaid
OH341537548026OtherCARE SOURCE
OH0489690Medicaid
OH341537548026OtherCARE SOURCE