=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235274929
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BALOGH & CEDARSTAFF OPTOMETRISTS, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2007
-----------------------------------------------------
Last Update Date | 10/14/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3737 45TH ST
-----------------------------------------------------
City | HIGHLAND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46322-3008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-924-6300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3737 45TH STREET
-----------------------------------------------------
City | HIGHLAND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-924-6300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE-PRESIDENT
-----------------------------------------------------
Name | DR. VALERIE J. BALOGH
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 219-924-6300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 18002093A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 18001942A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 18002093B
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 18001942B
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------