Basic Information
| Provider Information | |||||||||
| NPI: | 1821284464 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OPTIKS LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RON HAWKINS O.D. DBA OPTIKS | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 W KIRKWOOD AVE | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474046129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123319082 | ||||||||
| FaxNumber: | 8123311301 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 W KIRKWOOD AVE | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474046129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123319082 | ||||||||
| FaxNumber: | 8123311301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2007 | ||||||||
| LastUpdateDate: | 03/17/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAWKINS | ||||||||
| AuthorizedOfficialFirstName: | RON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OPTOMETRIST/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8123319082 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 000000338080 | 01 | ANTHEM | OTHER | 000000539394 | 01 | ANTHEM | OTHER |