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General NPI Number Information
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NPI Number | 1740520790
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Entity Type | Organization
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Legal Business Name | HOOSIER EYE DOCTOR INC
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Dates
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Enumeration Date | 02/27/2013
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Last Update Date | 04/12/2013
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Provider Practice Location Address
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Address Line | 4719 W STATE ROAD 46
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City | BLOOMINGTON
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State | IN
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Zip | 47404-9518
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Country | US
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Telephone | 812-876-2020
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Fax | 812-935-2020
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Provider Business Mailing Address
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Address Line | 4719 W STATE ROAD 46
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City | BLOOMINGTON
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State | IN
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Zip | 47404-9518
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Country | US
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Telephone | 812-876-2020
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Fax | 812-935-2020
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Authorized Official
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Title or Position | CO-MANAGER
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Name | JAN DITTMAN
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Credential |
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Telephone | 812-876-2020
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 18003199A
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License Number State | IN
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