Healthcare Provider Details

I. General information

NPI: 1417361403
Provider Name (Legal Business Name): DIANA PRLJEVIC OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 E MAIN ST
CARMEL IN
46032-1919
US

IV. Provider business mailing address

19 E MAIN ST
CARMEL IN
46032-1919
US

V. Phone/Fax

Practice location:
  • Phone: 317-669-2312
  • Fax:
Mailing address:
  • Phone: 317-669-2312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18003850A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number6310
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: