MEDICARE: OPHTHALMOLOGY CONSULTANTS OF FORT WAYNE, P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist
2	207W00000X	Ophthalmology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457334054
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPHTHALMOLOGY CONSULTANTS OF FORT WAYNE, P.C.

Provider Business Mailing Address
First Line	:	7232 ENGLE RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-2222
Country	:	US
Telephone Number	:	260-436-7205
Fax Number	:	260-432-1339

Provider Business Practice Location Address
First Line	:	10186 DUPONT CIRCLE DR E
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1638
Country	:	US
Telephone Number	:	260-436-7205
Fax Number	:	260-432-1339

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	TRICIA PIEPER
Credential	:
Telephone Number	:	260-969-1222

Provider Enumeration Date	:	11/29/2005
Last Update Date	:	08/05/2020

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