Healthcare Provider Details

I. General information

NPI: 1013989102
Provider Name (Legal Business Name): GARY W NESTY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 09/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 E NATIONAL AVE
BRAZIL IN
47834-2723
US

IV. Provider business mailing address

1515 E NATIONAL AVE
BRAZIL IN
47834-2723
US

V. Phone/Fax

Practice location:
  • Phone: 812-448-1898
  • Fax: 812-448-3838
Mailing address:
  • Phone: 812-448-1898
  • Fax: 812-448-3838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18001621
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: