Healthcare Provider Details

I. General information

NPI: 1144487315
Provider Name (Legal Business Name): GARY NESTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2008
Last Update Date: 01/27/2009
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: GARY NESTY
Title or Position: OWNER
Credential: DO
Phone: 812-448-1898