1053577510 NPI number — JERRY D WARTHMAN, O.D., LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053577510 NPI number — JERRY D WARTHMAN, O.D., LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JERRY D WARTHMAN, O.D., LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053577510
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1923 W 53RD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANDERSON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46013-1109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-644-0060
Provider Business Mailing Address Fax Number:
765-644-0076

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1923 W 53RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANDERSON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46013-1109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-644-0060
Provider Business Practice Location Address Fax Number:
765-644-0076
Provider Enumeration Date:
08/04/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WARTHMAN
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
DALE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
765-644-0060

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  18002286A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100331000B , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200953040 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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