Basic Information
| Provider Information | |||||||||
| NPI: | 1578637658 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETRY | ||||||||
| FirstName: | KURT | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 357C W MORGAN ST | ||||||||
| Address2: | |||||||||
| City: | SPENCER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474601219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128292972 | ||||||||
| FaxNumber: | 8128293639 | ||||||||
| Practice Location | |||||||||
| Address1: | 357C W MORGAN ST | ||||||||
| Address2: | |||||||||
| City: | SPENCER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474601219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128292972 | ||||||||
| FaxNumber: | 8128293639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 01/14/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 18002244B | IN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 000000087919 | 01 | IN | BCBS | OTHER | 351787030101 | 01 | IN | CARESOURCE | OTHER | 351787030 | 01 | IN | COMMERCIAL | OTHER | N283918 | 01 | IN | HARMONY HEALTH | OTHER | 100193710 C | 05 | IN | MEDICAID | 410022263 | 01 | IN | PALMETTO GBA/RAILROAD MEDICARE | OTHER |