1407909658 NPI number — 20 20 EYE SPECIALISTS PC

Table of content: (NPI 1407909658)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407909658 NPI number — 20 20 EYE SPECIALISTS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
20 20 EYE SPECIALISTS PC
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:
1407909658
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 366
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARY
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46402-0366
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-885-0116
Provider Business Mailing Address Fax Number:
219-881-0522

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2318 W 5TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARY
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46404-1331
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-885-0116
Provider Business Practice Location Address Fax Number:
219-881-0522
Provider Enumeration Date:
01/19/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WATKINS
Authorized Official First Name:
NEIL
Authorized Official Middle Name:
LAWRENCE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
219-885-0116

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  01039743A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207W00000X , with the licence number: 036086767 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 200043220 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 90001013 . This is a "BCBS OF IL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000219285 . This is a "ANTHEM BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 036097526 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".