Healthcare Provider Details

I. General information

NPI: 1306077839
Provider Name (Legal Business Name): NORTHSIDE EYECARE ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2009
Last Update Date: 01/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

634 CROSS VALLEY CIR
EVANSVILLE IN
47710-5238
US

IV. Provider business mailing address

634 CROSS VALLEY CIR
EVANSVILLE IN
47710-5238
US

V. Phone/Fax

Practice location:
  • Phone: 812-401-7777
  • Fax: 812-429-0392
Mailing address:
  • Phone: 812-401-7777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18003181
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18003164
License Number StateIN

VIII. Authorized Official

Name: DR. JEFFREY D. IRVIN
Title or Position: OWNER
Credential: O.D.
Phone: 812-401-7777