Provider Demographics
NPI:1972594257
Name:BEDNARCZUK, KEITH A (OD INC)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:A
Last Name:BEDNARCZUK
Suffix:
Gender:M
Credentials:OD INC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-1684
Mailing Address - Country:US
Mailing Address - Phone:513-932-3343
Mailing Address - Fax:513-932-0078
Practice Address - Street 1:777 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-1684
Practice Address - Country:US
Practice Address - Phone:513-932-3343
Practice Address - Fax:513-932-0078
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3215 T351152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0323019Medicaid
OH0540440001Medicare NSC
OH0323019Medicaid
OH4292891Medicare PIN