Holly Lee Hanbaum, OD

Primary specialty

OptometristTaxonomy code 152W00000X

License

3537T472 Issued in OH

Practice address

1010 North 21St St
Newark, OH 43055-2922

Phone

(740) 366-5050

Fax

(740) 366-4149

NPI assigned

Jan 30, 2006

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 2

Other names 1

• Holly Lee Petersilge Former name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1138579200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1283472000000",
    "number": "1225009913",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1010 NORTH 21ST ST",
            "city": "NEWARK",
            "state": "OH",
            "postal_code": "430552922",
            "telephone_number": "740-366-5050",
            "fax_number": "740-366-4149"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1010 NORTH 21ST ST",
            "city": "NEWARK",
            "state": "OH",
            "postal_code": "430552922",
            "telephone_number": "740-366-5050",
            "fax_number": "740-366-4149"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "HANBAUM",
        "first_name": "HOLLY",
        "middle_name": "LEE",
        "name_prefix": "Dr.",
        "credential": "OD",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2006-01-30",
        "last_updated": "2010-09-03",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "OH",
            "license": "3537T472",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0562850",
            "state": "OH"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE DURABLE",
            "identifier": "2267770001",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "HOLLY",
            "last_name": "PETERSILGE",
            "middle_name": "LEE",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

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• Optometrist in Newark, OH
• Providers in Newark, OH by specialty
• Optometrist in Ohio

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 3, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.