Healthcare Provider Details

I. General information

NPI: 1205825700
Provider Name (Legal Business Name): DR TAVEL OF EVANSVILLE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 BURKHARDT ROAD
EVANSVILLE IN
47715
US

IV. Provider business mailing address

2839 LAFAYETTE RD
INDIANAPOLIS IN
46222-2147
US

V. Phone/Fax

Practice location:
  • Phone: 812-473-3730
  • Fax: 317-924-3741
Mailing address:
  • Phone: 317-924-1300
  • Fax: 317-924-3741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18003203
License Number StateIN

VIII. Authorized Official

Name: DR. LARRY TAVEL
Title or Position: PRESIDENT
Credential: MD
Phone: 317-924-1300