Basic Information
| Provider Information | |||||||||
| NPI: | 1891748497 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY EYE CARE OF INDIANA, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 N RITTER AVE | ||||||||
| Address2: | STE 281 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462193052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173578663 | ||||||||
| FaxNumber: | 3173575383 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 N RITTER AVE | ||||||||
| Address2: | STE 281 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462193052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173578663 | ||||||||
| FaxNumber: | 3173575383 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 06/10/2011 | ||||||||
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| AuthorizedOfficialLastName: | LATONA | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3173578663 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 01044242A | IN | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 200275230A | 05 | IN | MEDICAID | 200275230C | 05 | IN | MEDICAID | 200275230B | 05 | IN | MEDICAID | DC5434 | 01 | IN | MEDICARE ID | OTHER |