Provider Demographics
NPI:1942499512
Name:WARREN EYE CLINIC INC
Entity Type:Organization
Organization Name:WARREN EYE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/EMPLOYEE
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:V
Authorized Official - Last Name:MARTUCCIO
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:330-395-2020
Mailing Address - Street 1:302 NILES CORTLAND RD NE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-1940
Mailing Address - Country:US
Mailing Address - Phone:330-395-2020
Mailing Address - Fax:330-395-6200
Practice Address - Street 1:302 NILES CORTLAND RD NE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-1940
Practice Address - Country:US
Practice Address - Phone:330-395-2020
Practice Address - Fax:330-395-6200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-05-7104-M207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0242393Medicaid
OH1254400001Medicare NSC
OHE84843Medicare UPIN
OH9246041Medicare PIN