Healthcare Provider Details

I. General information

NPI: 1447222872
Provider Name (Legal Business Name): JOHN M POLING OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 02/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2656 EAST SECOND STREET
BLOOMINGTON IN
47401
US

IV. Provider business mailing address

2656 EAST SECOND STREET
BLOOMINGTON IN
47401
US

V. Phone/Fax

Practice location:
  • Phone: 812-339-6131
  • Fax: 812-339-6161
Mailing address:
  • Phone: 812-339-6131
  • Fax: 812-339-6161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1368
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: