Basic Information
| Provider Information | |||||||||
| NPI: | 1235359480 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OPTOMETRIC ASSOCIATES OF SOUTH BEND | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 N IRONWOOD DR | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466152518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742893937 | ||||||||
| FaxNumber: | 5742807355 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 N IRONWOOD DR | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466152518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742893937 | ||||||||
| FaxNumber: | 5742807355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2007 | ||||||||
| LastUpdateDate: | 04/10/2008 | ||||||||
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| AuthorizedOfficialLastName: | MORLAN | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OPTOMETRIST | ||||||||
| AuthorizedOfficialTelephone: | 5742893937 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 152W00000X | 01 | IN | TAXONOMY | OTHER |