Provider Demographics
NPI:1689030413
Name:RAHARDJANOTO, LAURENCE (OD)
Entity type:Individual
Prefix:
First Name:LAURENCE
Middle Name:
Last Name:RAHARDJANOTO
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 TAYLOR STATION RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-4400
Mailing Address - Country:US
Mailing Address - Phone:614-866-9134
Mailing Address - Fax:614-866-6964
Practice Address - Street 1:245 TAYLOR STATION RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-4400
Practice Address - Country:US
Practice Address - Phone:614-866-9134
Practice Address - Fax:614-866-6964
Is Sole Proprietor?:No
Enumeration Date:2016-01-08
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOPT.6429152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist