Provider Demographics
NPI:1730175829
Name:COOPERRIDER, JON H II (OD)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:H
Last Name:COOPERRIDER
Suffix:II
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 1:484 PARK AVE W
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-3118
Mailing Address - Country:US
Mailing Address - Phone:419-525-0330
Mailing Address - Fax:419-525-3362
Practice Address - Street 1:484 PARK AVE W
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-3118
Practice Address - Country:US
Practice Address - Phone:419-525-0330
Practice Address - Fax:419-525-3362
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4014/T214152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0893332Medicaid
OH0780800001Medicare NSC
OH0674812Medicare PIN
OH0674813Medicare PIN
OH0780800002Medicare NSC
OH0893332Medicaid