Basic Information
| Provider Information | |||||||||
| NPI: | 1962575761 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DE SPIRITO | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | VINCENT | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1105 S COLLEGE MALL ROAD | ||||||||
| Address2: | HOOSIER EYE DOCTOR | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474016177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123232020 | ||||||||
| FaxNumber: | 8123342020 | ||||||||
| Practice Location | |||||||||
| Address1: | 1105 S COLLEGE MALL ROAD | ||||||||
| Address2: | HOOSIER EYE DOCTOR | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474016177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123332020 | ||||||||
| FaxNumber: | 8123342020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 03/26/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 18003199A | IN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 200411980A | 05 | IN | MEDICAID | 11478711 | 01 | CAQH | OTHER | 200411980 | 05 | IN | MEDICAID |