Basic Information
| Provider Information | |||||||||
| NPI: | 1356770333 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OSSIP OPTOMETRY, P.C | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SPENCER COMMUNITY EYECARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9795 CROSSPOINT BLVD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462563354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172546480 | ||||||||
| FaxNumber: | 3172598609 | ||||||||
| Practice Location | |||||||||
| Address1: | 357 W MORGAN ST STE C | ||||||||
| Address2: | |||||||||
| City: | SPENCER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474601255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128292972 | ||||||||
| FaxNumber: | 8128293639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2013 | ||||||||
| LastUpdateDate: | 10/13/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OSSIP | ||||||||
| AuthorizedOfficialFirstName: | GREGG | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3172546480 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 18002244 | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 201095580 | 05 | IN | MEDICAID |