Basic Information
| Provider Information | |||||||||
| NPI: | 1730523119 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DOCTORS PARK EYECARE LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | MAX A HENRY MD | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1930 DOCTORS PARK DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472032219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123724463 | ||||||||
| FaxNumber: | 8123722802 | ||||||||
| Practice Location | |||||||||
| Address1: | 1930 DOCTORS PARK DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472032219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123724463 | ||||||||
| FaxNumber: | 8123722802 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2013 | ||||||||
| LastUpdateDate: | 04/24/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HENRY | ||||||||
| AuthorizedOfficialFirstName: | MAX | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/MEDICAL DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 8123724463 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 01030454 | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 200823550 | 05 | IN | MEDICAID | 1295755841 | 01 | NPI | OTHER | 1730523119 | 01 | GROUP NPI | OTHER | 000000826911 | 01 | ANTHEM | OTHER |