MEDICARE: FORT WAYNE FAMILY EYECARE PC

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

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
2	000000234540	OTHER	IN	ANTHEM NONPAR

General Provider Information

NPI Number	:	1730112228
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT WAYNE FAMILY EYECARE PC

Provider Business Mailing Address
First Line	:	9426 LIMA RD
Second Line	:	SUITE C
City	:	FORT WAYNE
State	:	IN
Zip	:	46818-8934
Country	:	US
Telephone Number	:	260-489-5544
Fax Number	:

Provider Business Practice Location Address
First Line	:	9426 LIMA RD
Second Line	:	SUITE C
City	:	FORT WAYNE
State	:	IN
Zip	:	46818-8934
Country	:	US
Telephone Number	:	260-489-5544
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARK A INGLE
Credential	:	O.D.
Telephone Number	:	260-744-2273

Provider Enumeration Date	:	07/08/2006
Last Update Date	:	03/24/2014

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