=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962243121
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ISAAC GOTTSCHALK OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2024
-----------------------------------------------------
Last Update Date | 06/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1400 N BALDWIN AVE
-----------------------------------------------------
City | MARION
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46952-1929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-664-6148
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1400 N BALDWIN AVE
-----------------------------------------------------
City | MARION
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46952-1929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 18004495A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------