Provider Demographics
NPI:1053792424
Name:PERICHAK, NICHOLAS TYLER (OD, MS)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:TYLER
Last Name:PERICHAK
Suffix:
Gender:M
Credentials:OD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 N 21ST ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-2984
Mailing Address - Country:US
Mailing Address - Phone:740-366-5050
Mailing Address - Fax:
Practice Address - Street 1:1010 N 21ST ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-2984
Practice Address - Country:US
Practice Address - Phone:740-366-5050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-11
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6400152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist