Healthcare Provider Details

I. General information

NPI: 1235637075
Provider Name (Legal Business Name): MADISON EYE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2018
Last Update Date: 01/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 BROADWAY ST
MADISON IN
47250-3362
US

IV. Provider business mailing address

2932 BRECKENRIDGE LN STE 5
LOUISVILLE KY
40220-1490
US

V. Phone/Fax

Practice location:
  • Phone: 502-883-1015
  • Fax: 502-883-1019
Mailing address:
  • Phone: 502-371-9700
  • Fax: 502-540-3070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number02003914A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: MOHAMMAD A HAIDER
Title or Position: PRESIDENT
Credential: DO
Phone: 502-883-1015