Provider Demographics
NPI:1902854136
Name:KRIESSLER, SCOTT C (OD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:C
Last Name:KRIESSLER
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 1:5900 SOM CENTER RD
Mailing Address - Street 2:SUITE 19
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-3086
Mailing Address - Country:US
Mailing Address - Phone:440-585-2020
Mailing Address - Fax:440-585-2044
Practice Address - Street 1:5900 SOM CENTER RD
Practice Address - Street 2:SUITE 19
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-3086
Practice Address - Country:US
Practice Address - Phone:440-585-2020
Practice Address - Fax:440-585-2044
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4657 T1432152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHKRO802982Medicare ID - Type Unspecified
OHU 61470Medicare UPIN