Provider Demographics
NPI:1881698751
Name:MOREHEAD, JEFFERY L (OD)
Entity type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:L
Last Name:MOREHEAD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 BARKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-8736
Mailing Address - Country:US
Mailing Address - Phone:330-336-6878
Mailing Address - Fax:330-334-6061
Practice Address - Street 1:4500 MIDWAY MALL
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-2468
Practice Address - Country:US
Practice Address - Phone:440-324-5861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2010-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3038/T1523152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0204451Medicaid
OHMO 0815241Medicare ID - Type Unspecified
OHT46769Medicare UPIN