Healthcare Provider Details

I. General information

NPI: 1356675540
Provider Name (Legal Business Name): THE TRUSTEES OF INDIANA UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2009
Last Update Date: 09/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E ATWATER AVE
BLOOMINGTON IN
47405-3635
US

IV. Provider business mailing address

800 E ATWATER AVE
BLOOMINGTON IN
47405-3635
US

V. Phone/Fax

Practice location:
  • Phone: 812-856-5602
  • Fax: 812-855-6116
Mailing address:
  • Phone: 812-856-5602
  • Fax: 812-855-6116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. DOUGLAS G. HORNER
Title or Position: DIRECTOR OF CLINICAL ADMINISTRATION
Credential: O.D.
Phone: 812-855-4447