1780789909 NPI number — 20/20 EYE PHYSICIANS OF INDIANA, PC

Table of content: (NPI 1780789909)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780789909 NPI number — 20/20 EYE PHYSICIANS OF INDIANA, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
20/20 EYE PHYSICIANS OF INDIANA, 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:
20/20 PHYSICIANS OPTICAL
Provider Other Organization Name Type Code:
5
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:
1780789909
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2020 W 86TH ST
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46260-1969
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-871-5900
Provider Business Mailing Address Fax Number:
317-872-6439

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4880 CENTURY PLAZA RD
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46254-5469
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-328-0901
Provider Business Practice Location Address Fax Number:
317-328-5038
Provider Enumeration Date:
09/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
IRELAND
Authorized Official First Name:
DONNA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
317-871-5900

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  0003928578 , 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: CB2286 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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