Basic Information
| Provider Information | |||||||||
| NPI: | 1619137239 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARNER | ||||||||
| FirstName: | ADAM | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 E JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | TIPTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460721911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656753937 | ||||||||
| FaxNumber: | 7656753938 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 E JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | TIPTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656753937 | ||||||||
| FaxNumber: | 7656753938 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2008 | ||||||||
| LastUpdateDate: | 08/15/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 18003504A | IN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 200902760 | 05 | IN | MEDICAID |