Healthcare Provider Details

I. General information

NPI: 1649316936
Provider Name (Legal Business Name): EYESITE OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 12/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4405 BELLEMEADE AVE STE. 101
EVANSVILLE IN
47714-0682
US

IV. Provider business mailing address

4405 BELLEMEADE AVE STE. 101
EVANSVILLE IN
47714-0682
US

V. Phone/Fax

Practice location:
  • Phone: 812-474-1858
  • Fax: 812-485-2476
Mailing address:
  • Phone: 812-474-1858
  • Fax: 812-485-2476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18003248A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number01029433
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: DR. TIMOTHY M CROWLEY
Title or Position: OWNER
Credential: M.D.
Phone: 812-474-1010