Provider Demographics
NPI:1245478551
Name:BILPUCH, PEGGY JO (LDO)
Entity type:Individual
Prefix:MRS
First Name:PEGGY
Middle Name:JO
Last Name:BILPUCH
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 TAYWOOD RD
Mailing Address - Street 2:SUITE-A
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322-1856
Mailing Address - Country:US
Mailing Address - Phone:937-826-2020
Mailing Address - Fax:937-832-2916
Practice Address - Street 1:705 TAYWOOD RD
Practice Address - Street 2:SUITE-A
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-1856
Practice Address - Country:US
Practice Address - Phone:937-826-2020
Practice Address - Fax:937-832-2916
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-23
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5702-S156FX1800X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No332H00000XSuppliersEyewear Supplier