MEDICARE: BARRY J CLOSE OD, INC.

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	332H00000X	Eyewear Supplier	18001912	IN

General Provider Information

NPI Number	:	1912189507
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BARRY J CLOSE OD, INC.

Provider Business Mailing Address
First Line	:	2821 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-4732
Country	:	US
Telephone Number	:	260-482-9514
Fax Number	:

Provider Business Practice Location Address
First Line	:	2821 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-4732
Country	:	US
Telephone Number	:	260-482-9514
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BARRY JOSEPH CLOSE
Credential	:	OD
Telephone Number	:	260-482-9514

Provider Enumeration Date	:	12/05/2007
Last Update Date	:	03/17/2008

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