Healthcare Provider Details

I. General information

NPI: 1629280813
Provider Name (Legal Business Name): GREATER LAFAYETTE RETINA CENTER, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 06/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1013 N 13TH ST
LAFAYETTE IN
47904-2011
US

IV. Provider business mailing address

1013 N 13TH ST
LAFAYETTE IN
47904-2011
US

V. Phone/Fax

Practice location:
  • Phone: 765-428-8888
  • Fax: 765-428-8889
Mailing address:
  • Phone: 765-428-8888
  • Fax: 765-428-8889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number01057576A
License Number StateIN

VIII. Authorized Official

Name: PHYLLIS M. WATKINS
Title or Position: BILLING DEPARTMENT
Credential:
Phone: 765-428-8888