Provider Demographics
NPI:1740318542
Name:ABDUL QOTAYNAH O.D., INC.
Entity type:Organization
Organization Name:ABDUL QOTAYNAH O.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ABDULWAHED
Authorized Official - Middle Name:HAMOUD
Authorized Official - Last Name:QOTAYNAH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:440-974-6793
Mailing Address - Street 1:7850 MENTOR AVE
Mailing Address - Street 2:SUITE 368
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-5520
Mailing Address - Country:US
Mailing Address - Phone:440-974-6793
Mailing Address - Fax:440-974-6621
Practice Address - Street 1:7850 MENTOR AVE
Practice Address - Street 2:SUITE 368
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-5520
Practice Address - Country:US
Practice Address - Phone:440-974-6793
Practice Address - Fax:440-974-6621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5148 T2047152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2390087Medicaid
OHU83084Medicare UPIN
OH2390087Medicaid