Provider Demographics
NPI:1295973154
Name:GORTZ, KENNETH LEON (OD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:LEON
Last Name:GORTZ
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 1:1500 S COUNTY ROAD 1
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883-9746
Mailing Address - Country:US
Mailing Address - Phone:419-443-0710
Mailing Address - Fax:419-443-0576
Practice Address - Street 1:421A E WALTON ST
Practice Address - Street 2:
Practice Address - City:WILLARD
Practice Address - State:OH
Practice Address - Zip Code:44890-9108
Practice Address - Country:US
Practice Address - Phone:419-933-4327
Practice Address - Fax:419-933-4336
Is Sole Proprietor?:No
Enumeration Date:2009-01-30
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2891152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist