Provider Demographics
NPI:1932351681
Name:PLAZA OPTOMETRISTS INC.
Entity Type:Organization
Organization Name:PLAZA OPTOMETRISTS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:G
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:330-638-4097
Mailing Address - Street 1:20 W FEDERAL ST
Mailing Address - Street 2:SUITE T 4
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44503-1420
Mailing Address - Country:US
Mailing Address - Phone:330-638-4097
Mailing Address - Fax:330-637-0140
Practice Address - Street 1:3018 STATE ROUTE 5
Practice Address - Street 2:SUITE C
Practice Address - City:CORTLAND
Practice Address - State:OH
Practice Address - Zip Code:44410-9178
Practice Address - Country:US
Practice Address - Phone:330-638-4097
Practice Address - Fax:330-637-0140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-14
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3343 T420152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHNUMBERS PENDINGOtherNUMBERS PENDING