Basic Information
Provider Information | |||||||||
NPI: | 1790176394 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OSSIP OPTOMETRY, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | OSSIP FOCUS EYENOBLESVILLE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9795 CROSSPOINT BLVD | ||||||||
Address2: | STE 100 | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462563354 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3172546480 | ||||||||
FaxNumber: | 3172598609 | ||||||||
Practice Location | |||||||||
Address1: | 14540 PRAIRIE LAKES BLVD N | ||||||||
Address2: | STE 100 | ||||||||
City: | NOBLESVILLE | ||||||||
State: | IN | ||||||||
PostalCode: | 460604366 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3177708555 | ||||||||
FaxNumber: | 3177708558 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/18/2015 | ||||||||
LastUpdateDate: | 02/18/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DABELOW | ||||||||
AuthorizedOfficialFirstName: | RYAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE AND INSURANCE | ||||||||
AuthorizedOfficialTelephone: | 3172546480 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 01048750 | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   |
No ID Information.