Healthcare Provider Details

I. General information

NPI: 1881788735
Provider Name (Legal Business Name): OCULOFACIAL PLASTIC AND ORBITAL SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 05/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 PENNSYLVANIA PKWY SUITE 225
INDIANAPOLIS IN
46280-2301
US

IV. Provider business mailing address

201 PENNSYLVANIA PKWY SUITE 225
INDIANAPOLIS IN
46280-2301
US

V. Phone/Fax

Practice location:
  • Phone: 317-573-1000
  • Fax: 317-573-0205
Mailing address:
  • Phone: 317-573-1000
  • Fax: 317-573-0205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number01026942A
License Number StateIN

VIII. Authorized Official

Name: DR. WILLIAM R NUNERY
Title or Position: PRESIDENT
Credential: MD
Phone: 317-573-1000