Basic Information
| Provider Information | |||||||||
| NPI: | 1528475076 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERRON | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | VERWILST | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | VERWILST | ||||||||
| OtherFirstName: | LAURA | ||||||||
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| OtherCredential: | OD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2520 S BANTA AVE | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474033402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742987748 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 744 E 3RD ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474053603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128558436 | ||||||||
| FaxNumber: | 8128551683 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2014 | ||||||||
| LastUpdateDate: | 10/21/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046.010802 | IL | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 18003918A | IN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 201312970 | 05 | IN | MEDICAID |