Provider Demographics
NPI:1679700389
Name:DR. MARIA J. FRAGOULIS, INC
Entity type:Organization
Organization Name:DR. MARIA J. FRAGOULIS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FRAGOULIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-657-1301
Mailing Address - Street 1:5220 SPRUCE LN
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-9005
Mailing Address - Country:US
Mailing Address - Phone:614-209-8800
Mailing Address - Fax:614-901-9132
Practice Address - Street 1:8659 COLUMBUS PIKE
Practice Address - Street 2:
Practice Address - City:LEWIS CENTER
Practice Address - State:OH
Practice Address - Zip Code:43035-9699
Practice Address - Country:US
Practice Address - Phone:740-657-1301
Practice Address - Fax:740-657-8442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-20
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4104152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2615825Medicaid
OH4117971Medicare PIN
OHU12826Medicare UPIN