Provider Demographics
NPI:1932245909
Name:BURRIS, ROBERT O (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:O
Last Name:BURRIS
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 1:22524 RIVER CHASE LN
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-6869
Mailing Address - Country:US
Mailing Address - Phone:419-784-5329
Mailing Address - Fax:
Practice Address - Street 1:800 N CLINTON ST
Practice Address - Street 2:SUITE D
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-4610
Practice Address - Country:US
Practice Address - Phone:419-782-1901
Practice Address - Fax:419-782-2200
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2752152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0342516Medicaid
OH0342516Medicaid
OHBU0351781Medicare ID - Type Unspecified