Basic Information
| Provider Information | |||||||||
| NPI: | 1831268150 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ABBOTT EYE CLINIC INC PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | IMAGE OPTICAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2222 W LEXINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465141420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742943030 | ||||||||
| FaxNumber: | 5742943544 | ||||||||
| Practice Location | |||||||||
| Address1: | 2222 W LEXINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465141420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742943030 | ||||||||
| FaxNumber: | 5742943544 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 10/19/2012 | ||||||||
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| AuthorizedOfficialLastName: | ABBOTT | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5742943030 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 4018880001 | 01 | IN | DMER | OTHER |