Basic Information
| Provider Information | |||||||||
| NPI: | 1093870867 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALBORN | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 ESKENAZI AVENUE | ||||||||
| Address2: | FIFTH THIRD BANK BLDG., 5TH FLOOR | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462025166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178803851 | ||||||||
| FaxNumber: | 3178800403 | ||||||||
| Practice Location | |||||||||
| Address1: | 3840 N SHERMAN DR | ||||||||
| Address2: | ESKENAZI HEALTH CENTER FOREST MANO | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462264462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175413400 | ||||||||
| FaxNumber: | 3175413444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2006 | ||||||||
| LastUpdateDate: | 11/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 18003257 | IN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 201307120 | 05 | IN | MEDICAID |