Healthcare Provider Details

I. General information

NPI: 1225369572
Provider Name (Legal Business Name): NORTHWEST INDIANA EYE & LASER CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2010
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 S EDGEWOOD DR SUITE 5
KNOX IN
46534-8269
US

IV. Provider business mailing address

502 MARQUETTE ST
VALPARAISO IN
46383-2509
US

V. Phone/Fax

Practice location:
  • Phone: 574-772-2012
  • Fax:
Mailing address:
  • Phone: 219-464-8223
  • Fax: 219-531-2356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number01048897A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: SCOTT A BUCK
Title or Position: PRESIDENT
Credential: MD
Phone: 219-464-8223