Provider Demographics
NPI:1104139807
Name:KEITH A BEDNARCZUK OD INC
Entity type:Organization
Organization Name:KEITH A BEDNARCZUK OD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:A
Authorized Official - Last Name:BEDNARCZUK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:513-932-3343
Mailing Address - Street 1:777 COLUMBUS AVE
Mailing Address - Street 2:SUITE 12
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:SUITE 12
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-22
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3215/T351152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4292891Medicare PIN
OH0467061Medicare PIN