Provider Demographics
NPI:1952314585
Name:DAGOSTINO, GERALD JOSEPH (OD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:JOSEPH
Last Name:DAGOSTINO
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 1:5404 NORTHFIELD ROAD
Mailing Address - Street 2:
Mailing Address - City:MAPLE HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137
Mailing Address - Country:US
Mailing Address - Phone:216-587-6620
Mailing Address - Fax:216-587-6623
Practice Address - Street 1:5404 NORTHFIELD ROAD
Practice Address - Street 2:
Practice Address - City:MAPLE HTS
Practice Address - State:OH
Practice Address - Zip Code:44137
Practice Address - Country:US
Practice Address - Phone:216-587-6620
Practice Address - Fax:216-587-6623
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3716T397152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH341617718026OtherCARE SOURCE
OH0632613Medicaid
5369140001OtherDME
U31039Medicare UPIN
5369140001OtherDME