# FOUNTAIN ANTI-AGING

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- **Entity:** Organization
- **Status:** Active
- **Other names:** xRMD
- **Organization subpart:** No

## Provider details

- **NPI number:** 1154834562
- **Authorized official:** GEORGE WILLIAM ROZAKIS MD (CHAIRMAN)
- **Authorized official phone:** (216) 233-8503

## Contact information

- **Practice address:** 892 BEACH RD, LAKEWOOD, OH 44107-1018
- **Practice address phone:** (216) 233-8503
- **Practice address fax:** (216) 373-0044
- **Mailing address:** 892 BEACH RD, LAKEWOOD, OH 44107-1018
- **Mailing address phone:** (216) 233-8503

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207W00000X | Ophthalmology Physician | 243058-1 | NY | Yes |
| 207W00000X | Ophthalmology Physician | 56673 | CT | — |
| 207W00000X | Ophthalmology Physician | G142755 | CA | — |
| 207W00000X | Ophthalmology Physician | MD459908 | PA | — |

## Other

- **Enumeration date:** 11/07/2017
- **Last updated:** 03/17/2018

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 0655189 | — | OH |