Basic Information
| Provider Information | |||||||||
| NPI: | 1700966355 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOEHRLE | ||||||||
| FirstName: | MARY BETH | ||||||||
| MiddleName: | BETH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 9795 CROSSPOINT BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462563354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172546480 | ||||||||
| FaxNumber: | 3172598609 | ||||||||
| Practice Location | |||||||||
| Address1: | 980 S AVERITT ROAD | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461439450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178814143 | ||||||||
| FaxNumber: | 3172598609 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 09/09/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WV0400X | 8002492B | IN | N | Eye and Vision Services Providers | Optometrist | Vision Therapy | 152W00000X | 18002492A | IN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 200227780 | 05 | IN | MEDICAID | 351850049102 | 01 | IN | CARESOURCE | OTHER | 000000299181 | 01 | IN | BCBS | OTHER |