Healthcare Provider Details

I. General information

NPI: 1033560974
Provider Name (Legal Business Name): MARY ESDERS OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2016
Last Update Date: 06/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 S CREASY LN SUITE A
LAFAYETTE IN
47905-7430
US

IV. Provider business mailing address

1221 S CREASY LN SUITE A
LAFAYETTE IN
47905-7430
US

V. Phone/Fax

Practice location:
  • Phone: 765-447-4951
  • Fax: 765-447-4834
Mailing address:
  • Phone: 765-447-4951
  • Fax: 765-447-4834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18003968A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: