MEDICARE: FOUNTAIN SQUARE EYE CARE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	18002944A	IN

General Provider Information

NPI Number	:	1043614027
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOUNTAIN SQUARE EYE CARE

Provider Business Mailing Address
First Line	:	1429 SHELBY ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46203-1946
Country	:	US
Telephone Number	:	317-632-9220
Fax Number	:

Provider Business Practice Location Address
First Line	:	1429 SHELBY ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46203-1946
Country	:	US
Telephone Number	:	317-632-9220
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	RAJENDER MACHA
Credential	:	O.D.
Telephone Number	:	765-649-1200

Provider Enumeration Date	:	10/20/2014
Last Update Date	:	10/20/2014

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Directions to “FOUNTAIN SQUARE EYE CARE ” Practice Location

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