Provider Demographics
NPI:1508905241
Name:BLANK, FREDERICK DONALD
Entity type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:DONALD
Last Name:BLANK
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:FREDERICK
Other - Middle Name:DONALD
Other - Last Name:BLANK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:2512 CLARK AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44109-1111
Mailing Address - Country:US
Mailing Address - Phone:216-241-2040
Mailing Address - Fax:
Practice Address - Street 1:2512 CLARK AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-1111
Practice Address - Country:US
Practice Address - Phone:216-241-2040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH#2856152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0248084Medicaid
OH05278710000000Medicare ID - Type Unspecified