Provider Demographics
NPI:1720179617
Name:FORD, GERALD D (LDO)
Entity Type:Individual
Prefix:MR
First Name:GERALD
Middle Name:D
Last Name:FORD
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:NEW PHILADELPHIA
Mailing Address - State:OH
Mailing Address - Zip Code:44663-3829
Mailing Address - Country:US
Mailing Address - Phone:330-343-1215
Mailing Address - Fax:
Practice Address - Street 1:130 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:NEW PHILADELPHIA
Practice Address - State:OH
Practice Address - Zip Code:44663-3829
Practice Address - Country:US
Practice Address - Phone:330-343-1215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS488156FX1800X
OH488S332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1607729Medicaid
OH0657140001Medicare NSC