MEDICARE: NORTHSIDE EYE CENTER LLC

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

General Provider Information

NPI Number	:	1770266322
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHSIDE EYE CENTER LLC

Provider Business Mailing Address
First Line	:	9610 LIMA ROAD
Second Line	:	SUITE 103
City	:	FORT WAYNE
State	:	IN
Zip	:	46818-0104
Country	:	US
Telephone Number	:	260-440-8388
Fax Number	:	260-999-5645

Provider Business Practice Location Address
First Line	:	9610 LIMA ROAD
Second Line	:	SUITE 103
City	:	FORT WAYNE
State	:	IN
Zip	:	46818-9998
Country	:	US
Telephone Number	:	260-440-8388
Fax Number	:	260-999-5645

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	DR. BRANDON CALLOW
Credential	:	OD
Telephone Number	:	260-255-0654

Provider Enumeration Date	:	08/10/2023
Last Update Date	:	03/11/2024

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