Provider Demographics
NPI:1538168943
Name:FRIES, TIMOTHY D (OD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:D
Last Name:FRIES
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 1:207 GLENN AVE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON COURT HOUSE
Mailing Address - State:OH
Mailing Address - Zip Code:43160-1711
Mailing Address - Country:US
Mailing Address - Phone:740-335-2020
Mailing Address - Fax:740-335-1025
Practice Address - Street 1:207 GLENN AVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON COURT HOUSE
Practice Address - State:OH
Practice Address - Zip Code:43160-1711
Practice Address - Country:US
Practice Address - Phone:740-335-2020
Practice Address - Fax:740-335-1025
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5472 T2384152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2506550Medicaid
OHV02038Medicare UPIN
OH2506550Medicaid