Provider Demographics
NPI:1649442104
Name:ROBERT F GRADISEK OD INC
Entity type:Organization
Organization Name:ROBERT F GRADISEK OD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GRADISEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-282-6669
Mailing Address - Street 1:1142 W 37TH ST
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44052-5115
Mailing Address - Country:US
Mailing Address - Phone:440-282-6669
Mailing Address - Fax:
Practice Address - Street 1:1142 W 37TH ST
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44052-5115
Practice Address - Country:US
Practice Address - Phone:440-282-6669
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCM6489OtherRAILROAD MEDICARE
OH9236141Medicare PIN
OH0267530001Medicare NSC